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OPERATIVE  DENTISTRY 


LINDSAY  &  BLAKISTON'S 

DENTAL  PUBLICATIONS. 


PROFESSOR  HARRIS'S  TEXT-BOOK  OF  DENTISTRY.  Tenth  Revised 
and  Enlarged  Edition.  Edited  by  P.  H.  Austen,  M.D.,  Professor  of  Dental 
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409  Illustrations,  including  many  new  ones  made  especially  for  this  edition. 
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WEDL'S  PATHOLOGY  OF  THE  TEETH.  With  105  Illustrations.  Price, 
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LEBER  AND  ROTTENSTEIN'S  DENTAL  CARIES,  AND  ITS  CAUSES. 
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TOMES'  SYSTEM  OF  DENTAL  SURGERY.  Second  Edition,  Revised  and 
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^;^9*  Copies  sent  hij  mail,  free  of  postage,  upon  receipt  of  retuil  price. 
For  full  descrijition  of  the  above,  see  Catalogue  at  end  of  volume. 


L^  /"/  ^  ^  ^  ^ 


^/^. 


'^ 


x) 


A 


PRACTICAL  TREATISE 


OPERATIVE  DENTISTRY. 


By   J.    TAFT, 


PROFESSOR   OF   OPERATIVE   DENTISTRY   AND   DENTAL   HTGIENE   IN   THE   OHIO 
COLLEGE   OF   DENTAL   SDRGERT,   AND 

PROFESSOR    OF    PRINCIPLES   AND   PRACTICE   OP   OPERATIVE   DENTISTRY   IN   THE   DENTAL 
COLLEGE   OF   THE   UNIVERSITY   OF    MICHIGAN. 


THIRD    EDITION, 


ONE    HUNDRED   AND    TWENTY-EIGHT    ILLUSTRATIONS. 


PHILADELPHIA: 
LINDSAY    &     BLAKISTON 

1877. 

1^ 


Entereil.  according  to  Act  of  Congress,  in  the  year  1S77, 
BY    LINDSAY    &    BLAKISTON, 

In  the  office  of  the  Librarian  of  Congress,  at  Washington. 


I'RESS    OF    JIEXUV    n.    ASBIMKAI). 


-^^f- 


PREFACE. 

THIRD   EDITION. 


/A/U 
300 

(.?77 


So  great  have  been  the  changes,  in  almost  every 
branch  of  Dental  Practice,  since  the  publication  of 
the  second  edition  of  this  work,  that  the  labor  in- 
volved in  the  prejoaration  of  a  new  one  has  been  little 
less  than  the  writing  of  an  entirely  new  work. 

During  the  last  few  years  many  new^  instruments, 
appliances  and  modes  of  practice,  have  been  intro- 
duced, that  have  proved  very  valuable,  and  are  in 
use  by  the  profession,  superseding  in  many  cases 
others  less  efficient,  while  others,  again,  have  become 
wholly  obsolete  or  comparatively  worthless.  It  has 
therefore  become  necessary  to  omit  many  illustra- 
tions with  descriptions  of  them,  but  so  many  more 
have  been  added  that  are  now  regarded  as  desirable 
and  of  great  practical  value,  as  to  greatly  increase  the 
whole  number. 

The  general  scope  and  plan  of  the  work  has  not 
been  changed,  or  any  material  modification  made, 
except  adapting  it  more  fully  to  the  present  ad- 
vanced state  of  the  science.     An  Appendix  has  been 


Viii  PREFACE — THIRD    EDITION. 

added,  presenting  some  subjects  more  fully  than 
could  be  satisfactorily  done  in  the  body  of  the  woik. 
The  author,  in  conclusion,  cannot  refrain  from 
expressing  the  hope  that  this  edition  will  be  as 
favorably  received  as  the  previous  ones,  and  prove 
instrumental  in  promoting  the  best  interests  of  the 
profession. 

Cincinnati,  Juimarif,  1S77. 


PREFACE. 

SECOND   EDITION. 


The  preparation  of  the  present  edition  of  this  work 
has  been  attended  with  more  labor  and  effort  than 
the  author  had  anticipated. 

The  first  edition,  at  the  time  of  its  writing,  was 
designed  to  embody  and  present  the  principles  and 
practice  of  the  profession  in  the  operative  depart- 
ment, in  its  highest  attainment. 

Since  that  time,  however,  so  great  have  been  the 
changes  in  many  points  of  practice  and  application  of 
principles,  that  those  given  as  the  best,  nine  years 
ago,  are  superseded  by  others  and  out  of  use ;  so  that 
in  many  particulars  the  labor  has  been  almost  equal 
to  the  preparation  of  new  matter. 

The  object  in  this,  as  in  the  former  edition,  has 
been  to  bring  the  work  up  to  the  present  status  of 
the  profession ;  and  though  it  has  been  accomplished 
with  many  misgivings  and  consciousness  of  defects, 
the  author  is  not  without  hope  that  it  may  be  of 
value  to  those  preparing  to  enter  the  profession,  if 
not  to  those  already  in  it. 


CONTENTS. 


CHAPTER   I. 


Introduction, 
Deposits, 
Tai'tar,  .   . 

Its  Oi'igin,   . 

Points  of  Deposit 

Its  Effects,  . 

Method  of  Removin 
Green  Tartar, 

Its  Origin, 

Treatment,  . 
Irregularity, 

Effects, 
Atrophy, 

The  Cause, 

Effects,  . 
Exostosis, 

Its  Effects, 

The  Cause, . 
Denuding, 
Chemical  Abrasion, 

The  Cause, 
Necrosis  of  the  Teeth, 

Causes,  . 


PA(!E 

17 
18 
18 
19 
21 
22 
24 
25 
26 
28 
28 
30 
31 
32 
33 
34 
35 
36 
37 
38 
39 
41 
42 


CHAPTER  II. 

Caries  of  the  Teeth, 

Predisposing  Causes  of  Caries, 
Exciting  Causes  of  Caries, 
Comparative  Liability  to  Decay, 
Consequences  of  Caries, 
Treatment  of  Caries, 


44 
54 
59 
65 
67 
70 


Xii  CONTENTS. 

CHAPTER    III. 

PAGE 

General  Remarks  on  Filling,  ....  75 

Materials  for  Filling,  ,  .  .  .  .79 

Indestructibility,     .....  79 

Adaptability,     ......         80 

Hardness,    .  .  .  .  .  .  HO 

Non-conductor,  .  .  .  .  .81 

Cohesion,     .'  .  .  .  .  .  81 

Color,     .  .  .        •     .  .  .  .82 

Lead,  ......  83 

Tin, 84 

Silver,  ......  86 

Platinum,  ......         86 

Gold, 88 

Various  Preparations  of  Gold,  .  .  .90 

Crystal  Gold, 91 

Amalgam,  .  .  .  .  .  .93 

Oxy-chloride  of  Zinc,  ....  96 

Os  Artificial,      ......         96 

Non-metallic  Materials,      ....  97 


CHAPTEll   IV. 

Instruments  for  Filling,               .             .  .             .             .101 

Heavy  Cutting-instruments.      .             .  .             .              101 

Drills,  .......       104 

Bur  .Drills,  .             .             .             .  ,104 

Common  Drills,              .             .  .             .             .106 

Drill  Stocks,             .             .             .  .             .              108 

Excavators,  .             ,             .             .  .             .             .116 

Of  the  Manufacture  of  Excavators,  .             .              123 

Filling  Instruments,              .             .  .             .             .125 

The  File,             •            -             -             .  .             .              138 

The  Use  of  the  File,      .             .  .             .             .141 

Mode  of  Using  the  File,     ....  141 


CHAPTER   V. 

Separation  of  the  Teeth,  .  .  .  .  .145 


CONTENTS. 


Xlll 


CHAPTER   VI. 


PAflE 

Filling  Teeth,            ...... 

me 

Examination,             ...... 

157 

Opening  Cavities,            ..... 

IGl 

Removal  of  Decay,               ..... 

102 

Forming  Cavities,           ..... 

166 

Exclusion  of  Moisture,         ..... 

174 

Saliva  Pump,           ..... 

176 

Silk  Thread,      ...... 

179 

Clamps,        ...... 

179 

Elastic  Strap,     ...... 

182 

AVedges,       ...... 

182 

Jarvis'  Separators,         ..... 

183 

Chip  Blower,            ..... 

187 

Introducing  the  Filling,       ..... 

188 

Cylinder  or  Block  Filing,           .... 

194 

Forming  Blocks,            .             .             .             •             . 

195 

Introducing  the  Blocks,      .... 

l'.»8 

Pellets,  ..-.•.. 

201 

Cohesive  Foil,         .            .            .            .            • 

201 

The  Mallet,  ....... 

205 

Crystal  or  Sponge  Gold,             • 

210 

Finishing  Fillings,    ...... 

213 

CHAPTER  VII. 

Classification  of  Decayed  Cavities,  .... 

218 

Filling  by  Classes  and  Modifications, 

220 

First  Class,               ..... 

220 

Filling  with  Foil,  ..... 

229 

Cohesive  Foil,               .             .             •             . 

231 

Crystal  Gold,          ..... 

233 

Second  Class,          ..... 

236 

Third  Class,       ...... 

240 

Fourth  Class,           ..... 

245 

Fifth  Class,        ...... 

257 

Special  Cases,              .... 

263 

The  Palatal  portion  of  the  Crown  broken  away. 

leaving  the  outer  portion  standing — pulp  not 

exposed,              ..... 

264 

Filling  large  Cavities  on  the  Labial  Surfaces  of 

the  Superior  Incisors, 

269 

XIV 


CONTENTS. 


CHAPTER  Vlir. 

Pathological  Conditions, 
Sensitive  Dentine, 

Treatment  of  Inflamed  Dentine, 
Tannin  or  Tannic  Acid, 
Creosote,  or  Carbolic  Acid. 
Nitrate  of  Silver, 
Chloride  of  Zinc,  . 
Terchloride  of  Gold,    . 
Arsenious  Acid,     . 
Alkaline  Caustics, 


PAGE 

272 

272 
276 
279 
280 
280 
282 
284 
284 
287 


CHAPTER   IX. 

Exposed  Pulps.    ..... 

Treatment  of  Exposed  Pulps.    . 
Destruction  of  the  Pulp,     . 

Actual  Cautery, 

Potential  Cauter}', 

Arsenious  Acid, 
Application, 
Filling  Pulp-cavities  and  Canals, 
Preparing  the  Teeth  and  Roots  for  Filling, 
Dental  Periostitis, 

Treatment,         .... 
Alveolar  Abscess, 

Treatment,        .... 


289 
291 
305 
310 
311 
311 
313 
318 
325 
335 
338 
343 
348 


CIIAPTEIi    X. 


Pivot  Teeth, 

Fitting  the  Crown,    . 
Attachment  of  the  Crown, 
Metallic  Pivots, 


358 
363 
365 
370 


CHAPTER    XI. 
Extraction  of  Teeth, 

General  Remarks,    . 
Indications  for  Extraction. 
Extracting  Instruments, 
The  Key, 


370 
376 
383 
385 
387 


CONTENTS.  XV 

PAGE 

Forceps,         .......  391 

Elevators,           ......  403 

Hooks, 404 

Screw,     .......  404 

Gum-lancet,  .......  406 

The  Method  of  Lancing  the  Gunits.       .             .             .  408 

Extraction  of  the  Teeth,      .  .  .  .  .410 

Superior  Incisors,   .....  410 

Superior  Cuspids,          .....  412 

Superior  Bicuspids,             ....  414 

Superior  Molars,            .....  417 

Superior  Third  Molars,       ....  420 

Extraction  of  Roots,     .  .  .  .  .419 

Inferior  Incisors,    .....  423 

Inferior  Cuspids,            .....  424 

Inferior  Bicuspids,                ....  425 

Inferior  Molars,             .....  427 

Inferior  Third  Molars,        .             .             .             .  431 

Extraction    preparatory    to    the    Insertion    of  Artificial 

Dentures,         ......  432 

Conditions  to  be  observed  in  Extraction,    .             .             .  434 

CHAPTER   XII. 

Accidents  in  the  Extraction  of  Teeth,    ....  439 

Hemorrhage,       ......  440 

Treatment,         ......  442 

Fracture  of  the  Alveolus,           ....  451 

Laceration  of  the  Gums,      .             -             .             .             .  453 

Breaking  the  Teeth,       .....  453 

Removal  of  a  Wrong  Tooth,            ....  454 

Dislocation  of  the  Inferior  Maxilla,      .             .             .  457 

Syncope,       .......  459 


CHAPTER  XIII 

Anaesthetics, 

Ether — Chloroform, 
Nitrous  Oxide,    . 
Local  Anaesthesia,    . 

Congelation, 
Extraction  by  Electro-magnetism,  . 

Application, 


461 
461 
466 
468 
469 
472 
473 


xvi  CONTENTS. 

APPENDIX. 

PAGE 

Section  A. — Dental  Caries,          .....  475 

"      B. — Dr.  Corydon  Palmer's  Plugging  Instruments.  487 

"       C— Mallets, 495 

Automatic  Plugger  for  Engine,            .             .  499 

'*       D. — Matrices  for  Proximal  Fillings,      .             .             .  502 

"       E.— Salicylic  Acid,  .....  510 


OPERATIVE  DENTISTRY. 


CHAPTER  I. 

INTRODUCTION. 

Introductory  to  the  following  treatise,  some  con- 
sideration of  those  conditions  and  diseases  of  the 
teeth  which  require  the  aid  of  the  dental  surgeon, 
seems  appropriate.  To  refer,  however,  to  all  of 
these,  or  to  remark  at  length  upon  any  of  them,  is 
not  consistent  with  the  design  of  this  work,  or 
necessary  to  a  proper  understanding  of  the  subjects 
proposed.  Only  those  affections  which  pertain  to 
the  teeth  directly,  and  the  contiguous  parts,  will 
here  be  considered;  and  the  latter  only  so  far,  in 
the  main,  as  surgical  treatment  is  concerned.  Nor 
will  the  pathology  of  contiguous  parts  be  introduced; 
for  the  treatment  of  these,  being  mainly  therapeutic 
rather  than  surgical,  would  involve  a  discussion  of 
questions  not  within  the  scope  of  the  present  vol- 
ume.    Indeed,  it  is    proposed  merely  to   speak  of 


18  INTRODUCTION. 

those  affections  of  the  teeth  which  generally  suggest 
surgical  remedies,  and  which  are  implicated  more  or 
less  in  the  operations  described  in  the  following 
pages  ;  and  first,  of 

DEPOSITS. 

In  this  term  are  included  those  calcareous  forma- 
tions commonly  called  tartar^  a  certain  coloring 
matter  denominated  green  or  brown  stain,  and  such 
other  impurities  on  the  teeth  as  result  from  neglect, 
the  use  of  tobacco,  and  like  causes.     The  word 

TARTAR 

implies  all  calcareous  deposits  upon  the  teeth.  Of 
this  substance  there  are  several  varieties,  the  more 
obvious  of  which  have  respect  to  color,  composition 
and  consistence.  In  color,  there  are  all  shades,  from 
a  white,  with  slight  yellow  tint,  to  a  jet  black ;  and 
in  consistence,  all  degrees,  from  a  thick,  gummy 
mucus,  to  nearly  the  density  of  the  dentine  itself. 
The  color  will,  in  most  cases,  be  indicative  of  the 
density,  the  lightest  shade  corresponding  with  the 
softest,  and  the  darkest  with  the  hardest  consistence; 
there  will,  however,  be  found  some  variation  in  this 
respect.  The  tenacity  to  the  teeth  is  also  in  propor- 
tion to  the    density,  the  dense  and    dark   adhering 


TARTAR.  19 

most  firmly.  The  character  of  the  surface  of  the  tooth 
upon  which  the  deposit  is  made,  somewhat  modifies 
the  firmness  of  attachment.  The  density  of  the 
deposit,  too,  is  generally  indicative  of  the  rapidity  of 
its  formation,  being  in  an  inverse  ratio  to  this. 

All  the  varieties  of  tartar  are  composed  largely  of 
the  same  materials ;  though  the  proportions  vary 
much  in  different  cases, — phosphate  of  lime,  fibrin, 
fat,  and  animal  matter,  being  contained  in  them  all. 
The  fact  that  some  varieties  are  soluble  in  acids,  and 
others  not,  has  been  adduced  to  prove  that  they  are 
entirely  different  in  their  composition.  This,  how- 
ever, is  accounted  for  on  another  hypothesis  :  in  the 
softer  varieties,  the  phosphate  of  lime  is  so  protected 
by  the  fat  and  the  animal  matter  that,  under  ordinary 
circumstances,  acid  can  not  come  in  contact  with  it ; 
but  the  dense  varieties  are  very  soluble,  because  the 
acid  readily  comes  in  contact  with  the  calcareous 
material. 

Its  Origin. — The  calcareous  constituents  of  tartar 
are  brought  into  the  mouth  in  a  state  of  solution  in 
the  saliva,  being  secreted  from  the  blood  with  that 
fluid  ;  while  fats  and  other  animal  matter  are  accumu- 
lated from  food,  waste  from  the  surface  of  the  mucous 
membrane,  and  other  residual  matter  from  the  mucus, 
and  perhaps  the  saliva  as  well. 

This  calcareous  material,  which  consists  chiefly  of 


20  INTRODUCTION. 

phosphate  and  carbonate  of  lime,  is  precipitated  from 
the  saliva,  by  the  presence,  influence  and  operation 
of  several  agencies. 

The  saliva,  immediately  after  passing  from  the 
ducts  into  the  mouth,  undergoes  a  change  by  absorp- 
tion of  oxygen ;  intermingling  with  mucus  and  various 
foreign  matters  in  the  oral  cavity,  and  variations  of 
temperature,  that  greatly  diminish  its  solvent  power 
for  the  earthy  salts  referred  to.  Precipitation  now 
takes  place,  and  lodgment  is  made  upon  the  most 
susceptible  body  and  point  presented. 

Normal  saliva  always  holds  in  solution  more  or  less 
of  this  material;  and  sometimes  the  agencies  above 
referred  to  are  not  sufficient  to  reduce  its  solvent . 
power  to  the  point  of  precipitation,  or  letting  go  the 
material  held  in  solution.  It  is  very  probable  that 
in  some  cases  the  saliva,  very  soon  after  being  pro- 
jected into  the  mouth,  undergoes  change,  independ- 
ent of  the  causes  of  which  mention  has  been  made, 
quite  sufficient  to  permit  precipitation  of  the  salts  of 
lime  it  contains. 

Persons  of  a  lymphatic  temperament,  or  a  tendency 
toward  it,  with  muscles  of  a  soft,  flabby  texture,  hair 
light,  teeth  of  a  rather  inferior  quality,  and  a  free  flow 
of  saliva,  are  most  subject  to  the  accumulation  of 
tartar ;  yet  there  are  conditions  of  almost  all  consti- 
tutions in  which  it  is  freely  formed.     That  it  is  pre- 


TARTAR.  21 

cipitated  from  the  saliva,  is  a  fact  so  easily  demon- 
strated and  so  generally  admitted,  that  it  need  not 
here  be  considered. 

Points  of  Deposit. — The  points  at  which  salivary 
calculus  is  deposited  in  the  greatest  quantities  upon 
the  teeth,  are  in  the  vicinity  of  the  orifices  of  the  sali- 
vary ducts  ;  and  hence  it  is  found  most  abundant  on 
the  lingual  surfaces  of  the  inferior  anterior  teeth,  and 
on  the  buccal  surfaces  of  the  superior  molars.  Fre- 
quently, also,  it  collects  in  considerable  quantities 
upon  the  external  surfaces  of  the  inferior  front  teeth. 
The  points  to  which  it  most  readily  attaches,  are  at 
the  necks  of  the  teeth,  immediately  beneath  the  free 
margin  of  the  gum,  and  at  the  termination  of  the 
enamel  where  it  is  thickest.  A  nucleus  once  formed, 
and  it  encroaches  upon  the  crown  of  the  tooth,  if  no 
means  are  employed  to  prevent  its  lodgment,  at  a 
rate  determined  by  the  condition  of  the  saliva  and 
the  changes  to  which  it  is  subject.  ^-^ 

It  is  deposited  first  and  most  abundantly  on  the 
necks  of  the  teeth,  because  here  the  saliva  first  comes 
in  contact  with  these  organs,  and  here  remains  for 
the  longest  periods  and  in  the  largest  quantities. 
That  it  is  precipitated  very  soon  after  the  saliva 
enters  the  mouth,  is  evident  from  the  fact  that  it  is 
found  collected  upon  the  superior  molars,  just  in  the 
vicinity  of  the  orifices  of  the  ducts  of  Steno,  where 


22  INTRODUCTION. 

the   saliva  cannot  be  retained  for  any  considerable 
time,  by  reason  of  the  position,  but  must  very  soon 
pass  along  upon  the  surfaces  of  the  contiguous  teeth, 
on  which  it  is  generally  found   deposited  in  much 
smaller  quantities.      Such   is  the   condition   of   the 
saliva  sometimes,  either  from  being  surcharged  with 
the  calcareous  material,  or  from  weakness  of  solvent 
power,  that  precipitation  takes  place  before  elimina- 
tion of  the  saliva  from  the  ducts ;  and  so  masses  of 
the   solid   substance  have   been  found   in   the   duct 
passages ;  and  in  a  few  instances  have  been  found 
imbedded  in  the  salivary  glands.     Tumors  are  thus 
sometimes  found    that  seem   involved  in  great  ob- 
scurity, and  occasion  intense  and  prolonged  suffering. 
Its  Effects. — It  exercises  no  directly  injurious  influ- 
ence upon  the  substance  of  the  teeth  ;  but  it  is  highl} 
prejudicial  to  the  parts  immediately  in  connection 
with  them,  and  upon  which  they  depend  for  support. 
It  encroaches  upon  the  gums  and  alveoli,  and  causes 
absorption  of  these  important  surroundings ;  and  as 
they  become  destroyed,  its  encroachments  are  con- 
tinued and  accelerated.     In  some  constitutions  this 
process  goes  on  with  little  or  no   annoyance  to  the 
patient ;  while  in  others,  irritation,  inflammation,  and 
even  suppuration  of  the  gums,  occur ;  and  thus  their 
destruction  is   eff'ected  in  a  twofold  manner.     This 
irritation  and  inflammation  may  extend  to  the  mucous 


TARTAR.  23 

membrane,  and  involve  all  the  adjacent  parts.  The 
dental  periosteum  will  usually  become  implicated ; 
periostitis  will  ensue,  and  often  suppuration,  thus 
breaking  up  the  attachments  of  the  teeth  even  before 
the  surroundings  are  removed.  The  alveolus,  too, 
becomes  diseased,  and  in  some  instances  its  death 
and  exfoliation  result.  Salivary  calculus,  however, 
never  induces  caries  of  the  teeth,  nor  even  favors  it, 
except  by  inducing  disease  in  the  surrounding  parts. 
On  the  contrary,  we  frequently  meet  with  instances 
of  decay  entirely  arrested  and  deposit  of  tartar  in 
the  cavity. 

Persons  of  all  ages  are  subject  to  this  affection  ; 
those  past  middle  life  being  most  so,  and  those 
advanced  in  years  sometimes  having  teeth  nearly 
covered  with  tartar.     Occasionally  to  such  an  extent 

Fig.  1. 


do  the  roots  become  invested  with  it  that  the  teeth 
drop  from  the  sockets.  There  are  some  constitutions 
whose  diathesis  is  favorable  to  a  deposition  of  sali- 
vary calculus  through  life.  Others,  again,  will  be 
entirely  exempt  from  it  till  some  peculiar  constitu- 


24 


INTRODUCTION. 


tional  change   intervenes,  when  it  will  begin  to  be 
rapidly  produced. 

Method  of  Removing  it. — The  removal  of  salivary 
calculus  is  an  operation  that  does  not  involve  a  great 
amount  of  skill,  but,  with  suitable  appliances,  is 
easily  performed.  There  are  two  methods  of  effect- 
ing it;  the  one,  that  of  scaling  and  scraping,  and 
the  other,  that  of  decomposing  the  deposit  by  the 
application  of  an  acid.  The  former  is  always  to  be 
preferred ;  for,  in  the  latter,  the  chemical  action  of 
the  acid  does  not  stop  with  a  decomposition  of  the 
deposit,  but,  by  the  same  affinity,  and  nearly  as 
readily,  attacks  the  tooth  itself.  For  the  successful 
accomplishment  of  the  operation,  instruments  of 
various  forms  and  curves  will  be  necessary,  adapted 

Fit:.  2. 


and  adjusted  to  the  various  shapes  and  situations  of 
the  surfaces  to  be  operated  upon.  The  most  common 
forms  are   represented   in    the    above    figure.     The 


GREEN    TARTAR.  25 

blade  of  the  instrument  should  be  applied  at  a 
slightly  obtuse  angle  with  the  surface  of  the  tooth, 
just  beyond  the  edge  of  the  deposit  next  the  gum, 
and  thus  passed  under  the  tartar,  scaling  it  off  to 
the  point  in  such  a  manner  as  not  to  cut  or  abrade 
the  enamel.  Deposits  of  this  substance  on  proximal 
surfaces  of  the  teeth  are  to  be  carefully  observed, 
and  removed  with  instruments  of  attenuated  blades. 
When  the  thick  incrustations  have  been  thus  re- 
moved, the  surface  should  then  be  gently  scraped, 
so  as  entirely  to  clean  off  all  remaining  portions,  and 
afterward  thoroughly  polished  with  fine  pumice, 
Arkansas  or  rotten-stone,  and  finished  by  burnishing. 
During  the  operation,  a  frequent  employment  of  the 
toothbrush  with  water  will  be  required,  to  cleanse 
the  mouth  of  the  detached  material  and  the  increased 
secretions ;  and,  in  general,  the  completion  of  the 
process  will  occupy  more  than  one  sitting.  Since 
this  deposit  often  extends  beneath  the  free  margin 
of  the  gum,  much  care  is  necessary  to  see  that  it  is 
all  removed. 

GREEN   TARTAR., 

This  deposit  has  been  so  referred  to  by  writers, 
as  to  convey  the  impression  that  it  is  of  the  same 
generic  character  as  salivary  calculus.  Such  a  mis- 
apprehension is    hardly   pardonable.     The  teeth  of 


26  INTRODUCTION. 

young  persons  only  are  subject  to  this  affection,  it 
being  often  found  on  those  of  children  three  or  four 
years  old;  appears  on  the  labial  surfaces  of  the 
superior  front  teeth,  and  in  largest  quantity  near  the 
margin  of  the  gum.  It  is  seldom  seen  on  the  inferior 
teeth,  and  only  on  the  anterior  surfaces  of  the 
superior.  The  color  of  this  deposit  varies  from  a 
light  brown  to  very  dark,  inclining  to  green.  Wher- 
ever present,  the  surfaces  of  the  teeth  are  abraded, 
and  when  it  is  of  long  standing,  the  entire  enamel 
beneath  it  is  destroyed,  and  the  dentine  is  gradually 
involved  in  the  dissolution.  This  effect  upon  the 
teeth  is  not  produced  by  the  coloring  matter  observed 
upon  them,  but  by  an  acid  in  combination  with  this 
material  before  it  is  deposited.  The  stain  is  a  pre- 
cipitate from  this  compound,  and  the  acid,  leaving 
this,  combines  with  the  calcareous  ingredients  of  the 
teeth,  to  their  detriment  as  above ;  but  the  precipi- 
tate is  entirely  innocent,  so  far  as  decomposition  of 
the  teeth  is  concerned. 

Its  Origin. — Green  tartar,  or  green  stain,  doubtless 
has  its  origin  in  the  mucus,  when  this  is  in  a  particu- 
larly acid  condition.  That  it  does  not  proceed  from 
the  saliva,  is  proved  by  the  fact  that  it  is  never  found 
where  there  is  a  free  flow  of  saliva,  or  where  it  has 
free  access ;  but  the  point  of  its  deposit  is  where 
the   saliva  is  least  frequently  present,  being  most 


GREEN    TARTAR.  27 

abundant  in  cases  in  which  there  is  a  large  relative 
amount  of  mucus,  and  this  in  a  very  acid  condition. 
But  the  query  might  arise  here,  if  the  mucus  of  the 
mouth  were  wholly  in  that  condition,  why  would  not 
the  teeth  suffer  from  it  elsewhere  ?  Because,  on  the 
masticating  surfaces  of  the  teeth,  the  friction  of  the 
food  will  prevent  it,  and  on  the  inner  surfaces,  the 
friction  of  the  tongue ;  besides,  wherever  there  is  a 
free  flow  of  saliva,  this  will  have  a  counteracting 
effect.  Decay  goes  on  very  rapidly,  after  it  has  once 
commenced,  upon  teeth  affected  by  this  deposit. 

There  are  points  of  dissimilarity  between  this 
green  pigment  or  stain  and  salivary  calculus,  that  it 
may  be  well  to  notice.  The  latter  is  from  the  saliva; 
the  former  from  the  mucus ;  and  hence  the  one  exists 
where  there  is  an  abundant  flow  of  saliva,  and  the 
other  where  the  relative  quantity  of  this  is  small. 
The  calculus  is  deposited  when  the  saliva  is  hi  an 
alkaline  condition;  the  stain,  when  the  mucus  is  very 
acid.  The  former  is  deposited  in  large  quantities 
and  thick  incrustations,  and  upon  the  surfaces  of  the 
teeth,  and  is  easily  removed  without  detriment  to 
their  substance ;  whereas  the  latter  is  a  thin  film, 
barely  sufficient  to  stain  the  surface,  and  yet  it 
enters  into  the  tooth-substance  itself,  and  cannot  be 
removed  without  detaching  some  portion  of  the  tooth 
with  it.     The  one  seems  rather  preventive  of  caries. 


28  INTRODUCTION. 

which  does  not  occur  beneath  it ;  but  the  other  is 
highly  promotive  of  decay.  With  these  marked 
features  of  difference,  it  is  surprising  that  the  two 
should  ever  have  been  confounded,  since  it  is  so 
important  that  the  distinctive  character  of  each  be 
understood,  in  order  to  its  correct  treatment. 

Treatment. — In  order  to  a  perfect  and  final  remedy 
for  green  stain,  therapeutic  treatment  must  be  com- 
bined with  the  operative ;  but  only  the  latter  will  be 
here  described,  which  has  for  its  object  the  removal 
of  the  deposit,  and  the  rendering  of  the  eroded  sur- 
face smooth  and  polished.  There  are  two  or  three 
methods  of  accomplishing  this  object.  When  the 
erosion  is  but  slight,  it  can  be  effected  with  Arkansas- 
stone,  or  pulverized  pumice  and  water,  applied  with 
a  wooden  polisher  of  the  proper  form  till  the  stain 
disappears,  and  with  the  subsequent  use  of  the 
burnisher  with  a  solution  of  soap.  But  when  the 
erosion  is  too  extensive  to  be  thus  reduced,  it  must 
be  cut  down  with  a  file,  and  then  finished  with  stone 
and  burnished,  as  before.  And  when  the  erosion  is 
extreme,  a  cutting-instrument  may  properly  precede 
the  file. 

IRREGULARITY. 

By  this  term  we  imply  those  variations  from  a 
beautiful  and  natural  position  in  which  the  teeth  are 


IRREGULARITY.  29 

SO  frequently  found.  The  principal  cause  of  irregu- 
larity is  a  disproportion  between  the  size  of  the  arch 
and  the  space  required  for  the  accommodation  of  the 
teeth.  When  this  disproportion  exists,  the  teeth 
which  are  first  erupted  occupy  very  nearly  their 
proper  position ;  but  those  which  come  afterward,  are 
more  or  less  disarranged,  in  proportion  to  the  pre- 
occupation of  the  space.  There  are  cases  in  which 
the  roots  of  the  temporary  teeth  are  not  absorbed, 
and  the  permanent  teeth  are  erupted  out  of  their  true 
position,  even  when  there  is  room  enough  for  them 
were  the  former  removed.  Irregularity  is  mainly 
confined  to  the  front  teeth,  and  consists  in  either 
an  inward  or  an  outward  inclination,  and  in  some 
instances  both.  Sometimes  the  incisors  are  turned 
round  in  the  socket,  so  that  the  edge  stands  at  a  very 
considerable  angle  with  the  proper  position. 

The  upper  teeth  are  oftener  materially  disarranged 
than  the  lower,  though  the  latter  frequently  exhibit 
some  irregularity  in  front,  in  consequence  of  a  crowded 
condition.  The  teeth  most  liable  to  be  out  of  position 
are  the  cuspidate.  These,  of  the  teeth  of  replacement, 
are  the  last  in  their  eruption ;  and  it  often  occurs  that 
the  arch  is  previously  well-nigh  occupied,  in  which 
case  they  are  thrown  outward.  When  there  is  any 
irregularity  of  the  bicuspids,  it  is  usually  that  of  an 
inward  inclination.     The  first  and  second  molars  are 


30  INTRODUCTION. 

very  seldom  out  of  proper  position.  The  third  molars, 
however,  for  ^Yant  of  room,  are  sometimes  thrown 
out  toward  the  cheek,  or  even  prevented  from  coming 
out  at  all  in  any  direction. 

Effects. — In  all  cases,  irregularity  is  favorable  to 
decay.  It  is  even  maintained  by  some  that  the  organic 
structure  of  irregular  teeth  is  less  perfect  than  that 
of  regular,  because  the  former  are  impeded  in  their 
eruption,  and  thus  impaired.  But  this,  to  say  the 
least,  is  questionable ;  for  it  will  be  remembered  that 
the  crowns  of  the  teeth  are  formed  and  ossified  before 
they  can  be  much  affected  by  a  crowded  state ;  and 
it  is  hardly  probable  that  they  could  be  materially 
modified  in  their  structure  after  this  period.  The 
crowns  of  the  teeth  are  rarely  if  ever  deformed  by  a 
crowded  condition.  The  principal  cause  of  the  liability 
of  irregular  teeth  to  decay,  is  the  facility  they  furnish 
for  the  lodgment  of  foreign  substances  about  them, 
and  the  difficulty  they  present  to  its  removal.  And, 
again,  in  irregular  teeth,  parts  are  approximated  that 
nature  did  not  intend  should  be  brought  together. 
Irregularity  impairs  the  speech,  impedes  the  mastica- 
tion, and  often  distorts  the  countenance  and  deforms 
the  features. 


ATROPHY.  31 


ATROPHY. 


This  affection  is  characterized  by  defective  spots  in 
the  enamel, — white,  chalk-like, — which  scarcely  ever 
penetrate  the  dentine.  In  these  spots  there  is  little 
or  nothing  of  that  organic  structure  exhibited  by  well- 
formed  enamel.  They  are  usually  small,  but  vary 
greatly  in  number.  They  are  often  found  arranged 
in  transverse  rows  across  the  tooth  affected.  The 
superior  incisors  are  most  frequently  affected  with 
atrophy,  though  the  bicuspids  and  molars  sometimes 
exhibit  it.  The  front  upper  teeth  are  attacked  by  it 
only  on  the  anterior  surfaces. 

Instead  of  the  spots,  sometimes  pits  or  indenta- 
tions into  or  through  the  enamel  are  found,  which 
occasionally  run  together,  so  as  ultimately  to  form 
transverse  grooves  of  considerable  extent  upon  the 
teeth.  In  many  cases,  where  on  the  eruption  of  the 
teeth  the  spots  only  are  presented,  the  organs  are  not 
injured,  except  in  appearance,  the  spots  retaining  the 
smooth,  enamel-like  surfjice  during  life.  In  other 
cases,  the  spot  is  of  such  a  soft,  friable  texture,  that 
it  early  crumbles  out,  leaving  the  pits  above  referred 
to.  These  indentations,  however,  sometimes  exist  at 
the  first  appearance  of  the  tooth,  but  more  frequently 
afterward,  being  formed  by  the  disintegration  of  the 
defective  portion. 


32  INTRODUCTION. 

Atrophy  usually  occurs  on  teeth  of  good  structure, 
short,  thick  crowns,  and  rather  yellowish  color.  The 
long,  thin,  white  tooth,  of  imperfect  organization  and 
insufficient  density,  but  seldom,  if  ever,  presents  an 
atrophied  condition. 

The  Cause. — It  may  be  difficult  to  point  out  the 
precise  cause  of  this  affection,  but  some  facts  in  re- 
gard to  it  are  very  obvious.  There  is  in  every  case 
an  obstruction  in  the  development  of  the  enamel  at 
the  point  of  defect,  and  at  the  time  of  its  organiza- 
tion. In  some  cases,  doubtless,  there  is  a  deficient 
amount  and  an  inferior  quality  of  the  materials 
elaborated  for  the  upbuilding  of  the  structure ;  and 
this  is  probably  the  case  when  the  pits  exist  at  the 
eruption  of  the  teeth.  In  other  cases,  the  requisite 
quantity  of  materials  may  be  elaborated,  and  yet 
the  vital  energy  be  insufficient  to  organize  it,  as  in 
the  case  of  the  spots  referred  to.  The  latter  condi- 
tion is  more  frequent  than  the  former,  as  is  evidenced 
by  the  more  frequent  appearance  of  the  spots  than 
of  the  pits.  We  are  led  to  infer,  then,  that  the 
origin  of  this  affection  is  for  the  most  part  constitu- 
tional, and  not  local.  There  are  commonly  found 
traces  of  it  on  all  the  teeth  whose  enamel  was  in 
process  *of  formation  at  the  time  of  the  interruption. 

Any  general  disturbance,  such  as  to  interrupt  the 
assimilative   process,  would   be  detrimental   to  the 


ATROPHY.  33 

perfect  formation  of  the  tooth.  Again,  some  affec- 
tions may  materially  affect  the  organizing  power  of 
the  system  without  interfering  with  the  assimi- 
lative power.  Any  disease  that  interrupts  the  func- 
tions of  the  digestive  apparatus  is  prejudicial  to 
the  process  of  assimilation*  whilst  other  diseases, 
such,  for  instance,  as  those  of  a  febrile  character, 
would  diminish  the  vital  power,  and  consequently 
the  ability  to  build  up  organic  structures,  without 
interrupting  in  any  special  manner  the  process  of 
assimilation.  These  things  are  referred  to  here  for 
the  purpose  of  showing  under  what  circumstances 
atrophy  of  the  teeth  may  occur. 

Effects. — In  the  best  formed  teeth,  there  are  no 
unpleasant  results  from  atrophy  other  than  its 
detraction  from  their  beauty,  and  sometimes  being 
the  occasion  of  decay.  The  spots  are  unsightly, 
and  when  the  pits  are  present,  they  become  dark, 
and  sometimes  black,  from  deposit,  which,  by  ordi- 
nary means,  is  difficult  of  removal.  In  teeth  of 
inferior  structure,  decay  often  supervenes  in  these 
pits,  and,  extending  thence,  involves  the  other  parts; 
and  anything  that  will  affect  the  tooth-substance, 
will  find  a  beginning  place  in  these  spots. 


34  INTRODUCTION. 


EXOSTOSIS. 


This  term,  critically  defined,  implies  outgrowth 
from  a  hone  ;  but,  as  applied  to  the  bones  generally, 
and  particularly  to  the  teeth,  it  probably  conveys 
the  idea  of  grotvth  upon  the  hone.  The  affection  thus 
denominated  is  common  to  all  the  bones  j  some, 
however,  being  more  frequently  attacked  by  it  than 
others.  It  occurs  upon  the  roots  of  the  teeth,  but 
is  never  developed  where  there  is  no  periosteum. 
It  is  so  nearly  allied  in  structure  and  character  to 
the  cementum  that  covers  the  roots  of  the  teeth,  that 
it  may  be  regarded  as  hypertrophy  of  that  tissue. 
The  manner  of  its  accumulation  is  not  uniform ;  but 
it  commonly  consists  of  an  enlargement  on  the  point 
of  the  root,  or  from  the  point  some  distance  toward, 
and  occasionally  all  the  way  to,  the  neck  of  the 
tooth.  In  some  cases  it  extends  entirely  round  the 
root,  and  in  others  is  confined  to  one  side.  It  some- 
times results  in  such  an  enlargement  of  the  root, 
especially  if  it  is  near  the  point,  as  to  render  the 
tooth  very  difficult  of  removal.  When  the  root  is 
bulb-form,  its  attachment  may  be  broken  up,  so  as  to 
allow  it  to  rotate  in  the  socket,  and  yet  be  very 
difficult  to  remove ;  indeed,  in  some  instances,  im- 
possible, without  cutting  away  a  portion  of  the 
process. 


EXOSTOSIS.  35 

The  density  of  the  deposit  does  not  vary  much 
from  the  normal  cementum  of  the  root  on  which  it 
is  found,  though  in  this  respect  there  is  sometimes 
slight  variation ;  in  a  few  instances  we  have  found  it 
softer  than  the  root  proper.  The  surrounding  parts 
are  absorbed  for  its  accommodation.  The  color  of 
the  substance  is  slightly  yellow,  not  differing  much 
from  that  of  the  root  itself;  but  sometimes  it  ex- 
hibits a  semi-translucent  appearance.  The  rate  of  its 
formation  varies  considerably,  sometimes  increasing 
so  rapidly  as  to  occasion  difficulty,  by  impingement 
upon  the  surrounding  structure,  especially  nerve 
branches,  and  at  other  times  seeming  to  advance 
very  slowly;  and  frequently  it  is  arrested  altogether. 
Roots  are  often  found  affected  with  exostosis  that 
have  been  dead  and  crownless  for  a  number  of  years, 
and  yet  have  never,  so  far  as  known,  given  any 
trouble  because  of  the  affection.  Teeth  perfectly 
healthy  in  other  respects  may  be  thus  affected. 

Its  Effects  — It  always  increases  the  difficulty  of 
removing  the  tooth,  either  by  enlargement  of  the 
point  of  the  root  or  by  deposit  upon  one  side  of  it, 
causing  it  to  curve;  in  which  latter  case  the  difficulty 
is  all  the  greater,  from  the  impossibilit}^  of  deter- 
mining the  direction  of  the  curve.  It  sometimes 
produces  a  diseased  condition  of  the  surrounding 
parts — in  some  instances  chronic  inflammation — that 


36  INTRODUCTION. 

may  continue  as  long  as  the  tooth  remains.  Nervous 
affections  often  result  from  exostosis,  either  through 
irritation,  caused  by  pressure  on  the  pulp,  or 
through  the  diseased  condition  of  the  surrounding 
parts.  The  floor  of  the  antrum  is  sometimes  ab- 
sorbed away,  in  consequence  of  the  enlargement  of 
the  point  of  the  root ;  and  then  disease  of  the  lining 
membrane  of  that  cavity  may  occur. 

The  Cause. — The  cause  of  this  affection  is  not 
well  understood ;  though  much  light  has  been 
thrown  upon  it  by  the  researches  upon  the  reproduc- 
tion of  bone,  and  especially  so  far  as  the  function  of 
the  periosteum  is  concerned.  It  is  most  probably 
deposited  by  the  periosteum  when  this  is  in  an 
abnormal  condition ;  but  what  peculiar  condition,  it 
is  not  clearly  ascertained,  though  some  have  supposed 
it  to  be  inflammation.  It  is  patent,  however,  that 
something  more  than  a  state  of  simple  inflammation 
exists  ;  for  there  is  inflammation  in  numerous  in- 
stances without  this  deposit.  Again,  in  aU  cases 
where  there  is  periostitis,  that  state  is  definitely 
indicated  by  percussion  upon  the  affected  tooth; 
indeed,  in  the  occlusion  of  the  jaws,  pain  is  usually 
experienced.  Yet  there  are  found  many  teeth  whose 
roots  are  subjects  of  this  deposit,  that  have  never 
given  any  indications,  either  by  pain  or  otherwise, 
of  a  diseased  condition. 


DENUDING.  37 

This  subject  is  one  in  which  there  is  room,  at  least 
so  far  as  dentists  are  concerned,  for  more  extensive 
observation. 

DENUDING. 

This  consists  in  a  wasting  away  of  the  enamel  of 
the  anterior  teeth,  from  the  points  toward  the  necks. 
The  affection,  however,  is  of  too  rare  occurrence  to 
demand  extended  consideration.  The  color  of  the 
enamel  is  not  changed  by  this  process,  nor  is  its 
natural  polish  impaired  by  any  abrasion.  The  dentine, 
on  becoming  exposed  by  this  removal  of  its  natural 
protection  or  covering,  is  perfectly  smooth,  but  of  a 
yellowish  cast,  in  some  cases  inclining  to  brown. 
When  the  enamel  is  removed,  there  seems  to  be  a 
cessation  of  the  destructive  process ;  for  the  crowns 
of  such  teeth  will,  in  many  instances,  endure  for  a 
long  time — indeed,  till  they  are  worn  down  by  the 
friction  in  mastication. 

This  wasting  process  usually  begins  at  the  points 
of  the  teeth,  and  proceeds  toward  the  necks,  on  all 
sides,  till  the  enamel  is  entirely  destroyed.  Sometimes, 
however,  it  commences  on  their  labial  surfaces  ;  this 
is  particularly  the  case  with  the  superior  anterior,  but 
very  seldom  with  the  inferior  teeth.  The  affection, 
however,  attacks  the  inferior  more  frequently  than 


S8  INTRODUCTION. 

the  sui^erior  teeth ;  yet  it  is  found  assailing  both  with 
about  equal  energy. 

The  cause  of  this  affection  is  not  well  understood, 
though  it  is  generally  conceded  to  be  by  the  opera- 
tion of  an  acid  contained  in  the  mucus ;  and  this, 
with  but  little  doubt,  is  the  source  of  the  agent ;  for 
the  destructive  process  usually  occurs  where  there 
is  a  large  relative  amount  of  this  secretion ;  but 
that  it  is  an  agent  of  a  very  decided  acid  character, 
we  are  not  prepared  to  affirm.  Decay  of  the 
teeth  does  not  seem  to  progress  with  greater  rapi- 
dity while  this  affection  exists  than  at  other  times; 
and  again,  the  enamel  does  not  present  the  roughened, 
abraded  appearance  resulting  from  the  operation  of 
any  ordinary  agent.  With  these  apparently  incon- 
gruous facts,  it  is  rather  difficult  to  arrive  at  a  defi- 
nite conclusion  as  to  the  precise  manner  in  which  this 
condition  is  produced,  or  the  exact  character  of  the 
figent  instrumental  in  its  production. 

CHEMICAL    ABRASION. 

This  consists  in  a  gradual  destruction  of  the  entire 
substance  of  the  crown  of  the  tooth — the  enamel  and 
the  dentine.  It  is  an  affection  of  comparatively  rare 
occurrence.  It  attacks  the  superior  more  often  than 
the  inferior  teeth,  though  both  are  subject  to  it.     It 


CHEMICAL    ABRASION.  39 

begins  upon  the  points  of  the  central  incisors,  wasting 
them  away  more  rapidly  at  the  median  line,  from 
which  it  progresses  each  way,  involving  the  lateral 
incisors,  cuspids,  and  sometimes  the  bicuspids,  so  that 
a  curved  line  is  presented  by  the  edges  of  the  teeth, 
of  greater  or  less  inclination,  according  to  the  rapidity 
of  the  process.  When  the  superior  teeth  only  are 
affected,  the  opening  between  the  ends  of  the  upper 
and  of  the  lower  front  teeth,  when  closed,  is  a  semi- 
ellipsis.  If  the  inferior  teeth  are  affected,  as  is  some- 
times the  case,  then  the  opening  will  be  an  ellipsis. 

In  the  case  of  Mr.  G.,  the  affection  had  been  pro- 
gressing about  two  years  and  a  half;  the  wasting 
away  extended  to  the  first  bicuspids  both  above  and 
below ;  and  when  the  jaws  were  closed,  the  ends  of 
the  upper  and  of  the  lower  central  teeth  were  about 
one-third  of  an  inch  asunder,  and  the  opening  was  of 
the  elliptical  form.  It  was  a  mystery  to  him.  Two 
years  and  a  half  before,  his  anterior  teeth  shut  close 
together  on  the  ends.  He  had  not  used  them  in  the 
mastication  of  his  food,  for  his  molar  teeth  were  all 
good,  and  sufficient  for* this  purpose;  and,  moreover, 
it  had  been  impossible  for  him  to  use  them  in  masti- 
cation, since  he  could  not  bring  them  together ;  and 
he  had  not  been  in  the  habit  of  putting  any  hard 
substance  between  them. 

The  Cause. — The  cause  of  this  affection,  like  that 


40  INTRODUCTION. 

of  denuding,  is  not  well  understood.  It  is  supposed, 
however,  to  be  induced  by  an  acid  contained  in  the 
mucus.  If  this  supposition  is  correct,  it  must  be 
some  acid  with  whose  nature  we  are  but  little,  if  at 
all,  acquainted ;  or,  if  any  ordinary  acid,  it  certainly 
must  be  modified  by  very  peculiar  circumstances,  so 
that  it  effects  a  solution  of  both  the  animal  and  the 
earthy  constituents.  The  surface  upon  which  it  acts 
is  always  perfectly  smooth  and  polished,  never  pre- 
senting that  roughened  and  abraded  appearance  caused 
by  the  action  of  any  ordinary  acid  upon  enamel  or 
dentine.  And  again,  if  this  affection  results  from  the 
operation  of  an  acid  in  the  mucus,  why  does  not  this 
acid,  to  some  extent  at  least,  affect  the  teeth  at  other 
points  ?  Such  is  not  the  fact ;  and  caries  that  has 
previously  commenced  at  other  points  on  the  teeth, 
does  not  progress  more  rapidly  during  the  existence 
of  this  disease  than  before  ;  but  it  certainly  would 
if  there  were  a  large  quantity  of  acid  in  the  mucus. 

It  has  been  supposed  that  the  mucous  foUicles  of 
that  part  of  the  tongue  which  comes  in  contact  with 
the  teeth  at  the  affected  pari,  are  the  agents  that 
produce  the  disease.  Of  this,  however,  there  is  not 
evidence  sufficient  to  warrant  an  adoption  of  the 
theory.  The  cupping  of  the  molars  and  bicuspids 
bears  strong  indications  of  being  an  analogous  process, 
and  yet  no  such  influence  can  there  operate  for  its 


NECROSIS    OF   THE    TEETH.  41 

accomplishment.  We  have  no  theory  on  this  subject 
to  present,  regarding  it  as  still  an  open  field  for 
investigation.  There  can  be  little  doubt,  however, 
that  the  cause  of  denuding,  of  chemical  abrasion,  and 
of  cupping,  has  its  origin  in  the  constitution,  is  not 
merely  local,  and  may  be  removed,  and  the  affection 
arrested,  chiefly  by  constitutional  treatment. 


NECROSIS   OF    THE    TEETH. 

By  this  term  is  understood  the  death  of  the  part 
affected.  It  has  been  remarked  that  the  condition  is 
similar  to  mortification  in  the  soft  parts  of  the  sys- 
tem. But  in  the  latter  there  occurs  a  change  of 
structure ;  whereas,  in  the  bones,  and  particularly  in 
the  teeth,  there  is  not  necessarily  any  immediate 
structural  change  consequent  on  the  loss  of  vitality. 
The  teeth  have  their  organic  connection  with  the 
Surrounding  parts  by  the  external  and  the  internal 
periosteum  and  the  pulp ;  their  crowns  depend  chiefly 
for  vitality  upon  the  internal  organism,  as  is  evident 
from  the  total  loss  of  sensibility  in  them  immediatel}' 
after  the  destruction  of  the  pulp. 

Necrosis  of  the  teeth  differs  from  that  of  the  other 
bones  in  some  particulars,  one  of  the  most  obvious  of 
which  is,  that  in  the  former  there  is  no  exfoliation, 
the  living  structure  not  having  the  power  to  throw 


42  INTRODUCTION. 

off  the  dead  or  necrosed  portion.  x4.gain,  a  dead  part 
in  contact  with  the  living  does  not  materially  affect 
it.  The  roots  of  the  teeth  depending  for  their  vitality 
upon  both  their  internal  and  their  external  connec- 
tions, the  former  of  these  connections  may  be 
destroyed  without  materially  affecting  the  latter. 
Thus,  a  tooth  may  be  partially  necrosed, — that  is, 
vital  in  one  part  and  dead  in  another, — without  im- 
mediate injury  to  the  living  portion,  and  without 
separation  of  the  living  from  the  dead.  It  is  a  happy 
provision  that  the  analogy  between  the  teeth  and 
the  other  bones  does  not,  in  this  respect,  obtain ;  for 
if  it  did,  we  should  find  the  crowns  of  the  teeth 
separated  from  the  roots  in  all  cases,  immediately 
after  the  death  of  the  pulp. 

There  results  but  little  change  of  color  to  the  teeth 
from  necrosis,  unless  coloring  matter  is  absorbed  by 
the  dentine  from  the  decomposed  pulp;  though  of 
course  the  lifelike  lustre  and  appearance  of  the 
living  teeth  are  not  present.  Total  necrosis  destroys 
the  entire  organic  connection  of  the  teeth  with  the 
surrounding  parts,  in  which  case  they  are  very  soon 
expelled  from  their  sockets  as  useless. 

Causes. — Caries  is  a  very  common  cause  of  ne- 
crosis, especially  the  partial  form  of  it  to  which 
reference  is  made  above.  Protracted  fever,  or  dis- 
eases of  any  kind  that  diminish  the  vitality  of  the 


NECROSIS   OF   THE   TEETH. 


43 


constitution,  will  in  a  corresponding  degree  diminish 
that  of  the  teeth,  and  sometimes  destroy  it  entirely. 
Excessive  medication,  especially  with  mercurials, 
will  sometimes  produce  partial,  and  occasionally 
total,  necrosis,  as  w^ill  also  sometimes  blows  or 
violent  shocks,  when  these  are  not  sufficient  to 
displace  the  teeth.  Sudden  and  extreme  thermal 
changes  have  been  reckoned  causes  of  this  affection ; 
but  it  may  well  be  doubted  whether  they  are  ade- 
quate, without  the  concurrence  of  other  influences. 


CHAPTER  II. 


CARIES   OF    THE    TEETH. 


Notwithstanding  the  teeth  are  so  important  in  the 
human  economy,  having  functions  so  various  and  so 
extensive  to  perform,  they  are  greatly  neglected  in 
most  instances,  and  in  many  subjected  to  positive 
violence ;  as,  for  example,  in  crushing  or  biting  hard 
substances,  sustaining  weights,  and  suffering  severe 
blows,  sudden  extremes  of  temperature,  bungling 
dental  operations,  etc.  Very  few  give  that  attention 
to  these  organs  which  is  requisite  to  preserve  them 
from  injurious  influences ;  and,  owing  to  artificial 
modes  of  life,  and  consequent  impairment  of  health, 
this  is  often  difficult  to  do.  Indeed,  these  influences 
are  frequently  not  known,  and  the  causes  of  disease 
in  the  teeth  not  explored. 

Such  is  the  truth,  to  some  extent,  in  regard  to 
caries ;  though  this  affection  is  more  generally  a 
result  of  conditions  well  understood.  The  dentine 
is  affected  more  frequently  by  caries  than  by  any 
other  form  of  disease.  It  is  both  frequent  in  occur- 
rence  and   fatal    in   tendency.     Scarcely   any   that 


CARIES    OF   THE   TEETH.  45 

have  attained  maturity  are  exempt  from  its  ravages. 
It  is  a  disease  which  the  vital  forces,  owing  to  the 
nature  of  the  tissue,  can  but  feebly  withstand,  at 
least  with  far  less  efficiency  than  in  more  highly 
organized  structures ;  and  the  restorative  process  is 
wholly  inoperative  here.  Some  maintain  that  softened 
dentine  does  in  many  cases  regain  its  normal  density; 
but  this  cannot  be,  unless  it  retains  its  vitality.  But 
any  agent  possessed  of  sufficient  energy  to  decom- 
pose the  dentine,  will  destroy  its  vitality;  yet  a 
partial  removal  of  lime  salts  is  not  always  incom- 
patible with,  or  destructive  to,  vitality;  in  such  cases 
the  normal  density  of  the  affected  part  may  be  fully 
restored;  and  even  increased  growth  has  in  a  few 
instances  been  observed.  In  decay,  there  is  a  lack 
of  vital  power  to  maintain  the  integrity  of  the 
organic  structure,  or  there  is  the  action  of  some  agent 
having  an  affinity  for  a  certain  part  of  the  dentine 
more  potent  than  that  vital  power.  In  either  case, 
the  vitality  is  destroyed.  In  an  organized  structure, 
removal  of  one  of  its  essential  constituents  occasions 
a  loss  of  vitality. 

Caries  usually  makes  its  first  attack  upon  the 
dentine,  and  progresses  most  rapidly  in  the  direction 
of  the  tubuli.  There  are  variations  from  this  course; 
as,  for  example,  in  the  large  superficial  caries  on  the 
labial    surHxces   of  the   superior  incisors.     In  many 


46  CARIES    OF    THE    TEETH. 

cases,  too,  it  advances  immediately  beneath  the 
enamel.  Portions  of  the  dentine  imperfectly  pro- 
tected by  the  enamel,  on  account  either  of  an  injured 
condition  or  of  an  imperfect  formation  of  the  latter, 
are  liable  to  be  attacked  by  this  disease  ;  and  points 
that,  by  their  location  or  any  other  unfavorable  cir- 
cumstance, retain  injurious  agents  in  contact  with  the 
tooth,  are  very  subject  to  decay. 

The  attack  and  progress  of  caries  are  modified  by 
the  constitution  of  the  teeth.  These  may  be  defec- 
tive, either  originally  or  accidentally.  Original  de- 
fectiveness extends  to  all  the  teeth  of  the  same 
individual,  whilst  accidental  exists  only  as  to  some 
of  the  teeth  in  the  same  mouth,  and  these  only  at 
particular  points.  Such  conditions  are  peculiarly 
favorable  for  the  attack  of  caries.  When  the  whole 
crown  of  the  tooth  is  imperfectly  organized,  the 
decay  will  advance  with  uniform  rapidity,  under  the 
influence  of  uniformly  persistent  agents,  till  the 
whole  is  destroyed.  But  when  it  is  only  a  portion  of 
the  tooth,  the  caries  after  a  time  becomes  retarded 
in  its  progress,  and  in  some  cases  checked  altogether. 

Among  the  circumstances  which  modify  the  pro- 
gress of  this  disease,  are,  a  change  of  the  condition 
or  character  of  the  agencies  producing  it,  and  an 
increase  or  diminution  of  the  amount  of  such  agen- 
cies.    The  progress  of  caries  will  also  be  governed 


CARIES    OF    THE    TEETH.  47 

somewhat  by  the  age  of  the  person  whose  teeth  it 
attacks,  as  well  as  by  the  peculiar  constitution  of  the 
organs   themselves ;    for,   in  regard  to   constitution, 
they  present  an  almost  infinite  variety,  the  relative 
proportions  of  their  constituents  being   exceedingly 
various,  even  in  persons  of  the  same  age,  and  con- 
tinually varying  in  the  same  person  at  different  ages. 
There  is  a  constant  change  going  on,  the  calcareous 
elements  usually  increasing,  and  the  animal  decreas- 
ing.    But  a  proper  relative  amount  of  elements  may 
be  elaborated,  and  yet  a  defective  organization  exist. 
This  condition  arises  from  defective  organizing  power, 
or  from  a  failure  in  arrangement  and  combination  of 
the   materials,   and   is    dependent   entirely   on   acci- 
dental causes.     In  vital  energy,  indeed,  the   teeth 
exhibit  great  diversity;  and   this  corresponds  with, 
and  to  some  extent  depends  upon,  the  vital  energy 
of  the  general  constitution.     Dead  dentine  is  decom- 
posed more  readily  than  living ;  and  hence  the  con- 
clusion  that   vitality    resists    caries,   and    that    this 
resistance  corresponds  with  the  vigor  of  the  vitality. 
The  points  most  frequently  attacked  by  caries  are 
the  proximal  surfaces  of  the  teeth,  the  indentations 
and  fissures  on  the  masticating  surfaces  of  the  molars 
and  bicuspids,   the  longitudinal  depressions  on  the 
buccal  and  palatal  walls  of  the  molars,  and  the  necks 
of  the  teeth  at  the  termination  of  the  enamel.     On 


48  CARIES    OF   THE    TEETH. 

the  proximal  surfaces,  the  enamel  is  thinner  than 
elsewhere ;  and  the  situation  is  peculiarly  favorable 
for  the  accumulation  and  retention  of  injurious 
agents.  The  union  of  the  enamel  in  the  fissures 
and  indentations  of  the  crowns  of  the  molars  is 
often  imperfect;  and  thus  there  is  a  way  of  entrance 
for  vitiated  fluids  to  the  dentine.  Decay  is  found 
at  the  terminations  or  intersections  of  these  fissures 
earlier  than  at  any  intermediate  points.  The  inden- 
tations, or  grooves,  on  the  sides  of  the  teeth  are 
usually  attacked  by  caries  at  that  point  next  to  the 
neck.  Less  frequently,  the  disorder  is  exhibited  at 
the  neck,  just  beneath  the  border  of  the  enamel, 
under  which  it  burrows  with  a  transverse  extension. 
The  order  in  which  the  elements  are  removed  is 
governed  by  the  nature  of  the  agent  which  effects 
the  decomposition;  and  this  is  usually  one  having 
an  affinity  for  the  calcareous  elements  strong  enough 
to  destroy  the  texture  of  the  dentine,  and  remove 
the  earthy  portion.  Those  acids  which  have  an 
affinity  for  the  lime  of  the  dentine,  produce  its 
decomposition  in  this  manner.  When  the  decay  is 
thus  caused,  the  portion  remaining  in  the  cavity  is 
soft,  and  approximates  the  gelatinous  condition  as 
the  calcareous  material  is  abstracted.  Agents  of  a 
different  character,  too,  often  produce  decay.  Alka- 
lies will  act  upon  the  animal  portion  of  the  dentine. 


CARIES    OF   THE   TEETH.  49 

and  remove  it;    and  in   caries   thus   produced,  the 
residue  is  friable  and  chalk-like. 

In  other  cases  the  constituents  are  simultaneously 
removed.  Nitric  acid  will  cause  an  entire  breaking- 
up  of  both  the  earthy  and  the  animal  constituents. 

The  dentine  outside  of  the  decay  may  be  in  an 
inflamed  and  irritable  condition,  so  that  the  contact 
of  an  instrument  with  the  decayed  portion  will 
produce  pain :  and  thus  we  may  be  led  falsely  to 
conclude  that  the  softened  dentine  is  sensitive ;  and, 
indeed,  it  is  maintained  that  in  some  cases  the 
partially  decomposed  dentine  is  so,  on  the  suppo- 
sition that  a  Somali  portion  of  the  calcareous  elements 
may  be  removed,  and  yet  the  vitality  of  the  part 
not  be  destroyed. 

The  progress  of  caries  is  far  more  rapid  in  the 
crowns  of  the  teeth  than  in  the  roots,  for  the  reason 
that  the  former  are  more  exposed  to  the  influences 
of  external  injuries.  It  is  true  that  the  crowns  are 
covered  by  enamel,  which  is  designed  to  shield  the 
dentine  from  injury;  but  this  is  often  deJ^ctive, 
and  on  it  are  accumulated  agents  that  it  cannot 
resist  even  when  it  is  perfect,  so  that  the  enamel 
itself  is  sometimes  decomposed.  The  roots,  too, 
possess  a  higher  degree  of  vitality  than  the  crowns, 
and  their  ability  to  resist  the  encroachments  of 
decay   is    correspondingly   greater;    and    hence    we 


50  CARIES    OF   THE    TEETH. 

often  find  the  roots  of  teeth  solid  and  free  from 
decay,  the  crowns  of  which  have  been  removed  by 
rapid  decomposition.  Injurious  substances  are  some- 
times pressed  into  contact  with  the  dentine  through 
defects  in  the  enamel,  or  under  its  projections,  and 
there  retained  till  theii'  mischievous  effect  is  pro- 
duced. 

It  is  maintained  by  some  writers  that  caries  is 
contagious.  Dr.  Koecker  was  of  this  opinion.  The 
question,  then,  is,  whether  there  is  any  property  in 
the  decayed  dentine  of  one  tooth  capable  of  pro- 
ducing the  same  condition  in  the  healthy  dentine  of 
another?  The  residue  of  abnormal  dentine  in  the 
soft  decay  consists  of  the  animal  elements  and  a 
small  portion  of  earthy  material;  and  in  decay  in 
which  the  gelatinous  constituent  is  abstracted,  the 
remainder  is  chalk-like,  consisting  mainly  of  phos- 
phate of  lime.  In  neither  of  these  is  there  anything 
that  can  possibly  operate  on  the  healthy  dentine. 
There  is  one  thing  here,  however,  that  is  worthy  of 
remark,  and  that  has  perhaps  led  to  the  mistaken 
notion  that  caries  is  contagious :  decayed  dentine 
will  absorb  and  retain  fluids  that  injuiiously  affect 
sound  dentine;  and  when  the  decay  is  on  the 
proximal  portion,  two  teeth  are  subject  to  the  same 
exciting  cause.  But  it  is  seldom  that  two  teeth 
thus  situated  are  both  in  the  same  stage  of  decay — 


CARTES    OF    THE    TEETH.  51 

a  fact  principally  attributable  to  the  difference  in 
their  constitution.  The  decay  of  the  teeth  in  pairs 
has  also  been  adduced  as  evidence  of  the  contagious 
character  of  the  disease.  This,  however,  results 
from  the  fact  that  the  pairs  are  formed  at  the  same 
time,  are  subject  to  the  same  influences  in  their 
formation,  and  hence  are  constituted  alike ;  and  if  one 
of  the  pair  is  defective,  the  other  will  probably  be 
in  a  like  condition.  When  there  is  a  vitiation  of  the 
saliva  or  mucus,  they  will  be  similarly  affected.  In 
no  common  acceptation  of  the  term  contagious  can 
it  be  applied  to  caries  of  the  teeth. 

The  color  of  caries  is  exceedingly  various,  from  that 
of  healthy  dentine,  through  every  intermediate  shade, 
to  jet  black.  The  rate  of  the  progress  is  indicated  by 
the  color  of  the  decay,  being  slower  as  this  is  darker, 
so  that  when  the  decay  becomes  almost  stationary, 
the  affected  portion  is  usually  black.  The  degrees  of 
color  are  differently  enumerated  by  different  writers ; 
as,  by  Koecker  five, by  others  seven, and  so  on.  Three, 
however,  are  sufficient  for  our  purpose  :  white,  brown, 
and  black.  The  sensitiveness  of  the  dentine  is  greatest 
in  teeth  affected  by  the  white  decay,  and  usually 
decreases  as  the  color  darkens;  though  there  are 
exceptions  to  this  rule,  for  occasionally  the  teeth 
affected  by  dark  decay  are  quite  sensitive.  The 
light-colored  decay  is  more  difficult  to  arrest  than  the 


52  CARIES    OF    THE   TEETH. 

dark.  In  many  cases  of  the  former,  filling  seems 
hardly  to  retard  its  progress ;  whereas  in  the  latter, 
by  proper  filling,  the  advance  of  the  decay  may  be 
checked  altogether.  The  cause  of  the  dark  color  of 
caries  is  not  perfectly  understood,  but  is  probably 
owing  to  the  carbonization  of  the  animal  portion. 

The  opinion  is  entertained  by  some  that  this  dark 
material  protects  the  dentine  from  the  influence  of 
injurious  agents.  But  this  is  most  probably  not 
correct,  at  least  to  any  perceivable  extent.  If  it  does 
thus  serve  as  a  protection,  its  removal  would  subject 
the  dentine  to  a  renewed  attack  of  caries,  which 
experience  assures  us  it  does  not  do.  Those  who  main- 
tain this  opinion,  refer,  in  support  of  it,  to  the  fact 
that  when  a  deposit  of  oxyd  of  silver  is  made  upon 
a  decay  of  light  color,  by  the  use  of  nitrate  of  silver, 
the  progress  of  the  decay  is  thereby  retarded.  This 
retardal,  however,  is  effected  more  probably  by  a 
change  in  the  character  of  the  decay  than  by  any 
protection  afforded  by  the  coating  of  oxyd  of  silver. 

Some  sensitiveness  commonly  accompanies  caries. 
It  does  not  often  amount  to  pain,  but  is  rather  a  sense 
of  uneasiness ;  yet  from  change  of  temperature,  or 
contact  of  acids  or  hard  substances,  intense  pain  may 
be  produced.  Dr.  Koecker  remarks  that  caries  is 
most  tender  in  its  first  stages;  and  Dr.  Cone  that 
when  a  tooth  is  attacked  by  it,  the  sensitiveness  is 


CARIES    OF   THE   TEETH.  53 

increased.  The  surface  of  the  dentine,  or  that  part 
united  to  the  enamel,  is  susceptible  of  the  most  acute 
sensitiveness.  When  there  is  inflammation  of  the 
dentine,  intense  pain  may  be  produced  by  the  contact 
of  an  instrument,  in  a  cavity  of  decay,  at  the  line  of 
union  of  the  dentine  with  the  enamel,  with  very 
little  sensitiveness  present  elsewhere  in  the  cavity. 
Sensitiveness  of  a  uniform  character  sometimes  per- 
vades all  parts  of  the  cavity,  while  at  other  times 
it  may  be  very  intense  at  one  point,  and  very  slight 
or  entirely  absent  at  any  other.  A  thin  lamina  of  the 
dentine  lining  the  whole  cavity  may  be  uniformly 
sensitive,  and  in  some  cases  sensitiveness  involves 
the  entire  body  of  the  dentine. 

By  means  of  this  sensitiveness,  warning  is  trans- 
mitted to  the  pulp,  which  emits  osseous  material  with 
increased  energy  ;  and  thus  a  process  of  filling  up  the 
natural  cavity  of  the  tooth  is  instituted,  that  the  decay 
may  not  encroach  upon  the  pulp.  But  this  warning 
may  in  some  degree  be  transmitted  to  the  pulp 
though  there  be  no  appreciable  increase  of  sensitive- 
ness. 

This  sensitiveness  is  modified  by  the  character  of 
the  teeth,  the  nature  of  the  decay,  and  the  state  of 
the  patient's  constitution.  The  teeth  of  the  same 
person  will  be  more  sensitive  at  one  time  than  at 
another,  because  of  a  greater  irritability  of  the  nervous 


54  CARIES    OF    THE   TEETH. 

system.  Those  teeth  which  decay  most  rapidly  are 
usually  most  sensitive ;  though  in  teeth  whose  vitality 
is  lost  considerably  in  advance  of  their  decay,  there 
is  no  perceptible  sensitiveness  at  all.  Except  in  such 
cases  as  last  mentioned,  the  whitest  and  most  rapid 
decay  has  most  sensitiveness,  the  brown  much  less, 
and  the  black  scarcely  any. 


PREDISPOSING    CAUSES    OF    CARIES" 

The  causes  of  caries  of  the  teeth  may  be  considered 
under  two  general  divisions — predisposing  and  excit- 
ing. Of  the  former  some  are  original,  others  acci- 
dental. The  original  development  of  the  constitution 
may  be  defective,  either  from  original  or  from  acciden- 
tal defect  in  the  parent,  but  more  certainly  from  the 
former.  Constitutional  characteristics  are  transmis- 
sible, and  a  defect  is  as  surely  hereditary  as  anything 
else.  In  the  fetus,  during  gestation,  germs  may  have 
originated  from  which  perfect  organs  can  never  be 
developed,  and  these  germs  may  be  more  or  less 
defective  according  to  the  constitutional  condition  of 
the  mother,  or  according  to  accidental  conditions  to 
which  she  may  be  subject,  and  which  may  seriously 
affect  the  fetus.  After  birth,  too,  the  child  is  exposed 
to  injurious  impressions,  which  will,  to  a  greater  or 
less  degree,  render  the  development  defective;   as 


PREDISPOSING   CAUSES    OF    CARIES.  55 

imperfect  nourishment  and  the  diseases  and  functional 
derangements  peculiar  to  childhood.  A  diseased 
condition,  or  functional  derangement,  will  interrupt 
the  proper  elimination  and  perfect  upbuilding  of  the 
materials  necessary  for  the  perfect  structure ;  and 
indeed  anything  that  will  disturb  the  equilibrium  of 
action  in  the  system  may  be  detrimental  to  the 
teeth. 

In  some  instances  the  teeth  will  exhibit  the  pecu- 
liarities of  the  mother,  and  in  others  those  of  the 
father,  while  sometimes  they  simulate  those  of  both 
parents ;  and  when  the  parental  imprint  is  thus  found 
stamped  on  the  teeth,  it  will  also  be  found  that  those 
of  the  same  class  decay  at  the  same  points  and  at 
about  the  same  age  as  in  the  parent.  In  such  cases 
the  defect  is  manifestly  hereditary;  it  cannot  be 
accidental :  the  coincidences  thus  constantly  occur- 
ring preclude  any  other  conclusion.  Hereditary  taint, 
then,  may  be  regarded  as  a  predisposing  cause  of 
caries. 

Impaired  vitality  is  another  predisposing  cause ; 
and  not  only  impaired  vitality  of  the  teeth  and  con- 
tiguous parts,  but  also  that  of  the  general  system. 
Indeed,  the  vital  vigor  of  the  teeth  depends  upon 
that  of  the  general  system,  and,  when  there  is  no 
local  adverse  influence  at  work,  corresponds  with  it ; 
so  that  when   the   general   system  is   in   the  most 


56  CARIES    OF    THE   TEETH. 

healthy  condition,  the  teeth  possess  the  greatest 
power  of  resistance  to  deleterious  agencies.  This 
resisting  power  is,  at  best,  comparatively  feeble ;  but 
its  feebleness  is  to  some  extent  compensated  by  the 
peculiar  structure  of  the  teeth,  which  are  less  liable 
to  decomposition  than  any  other  part  of  the  human 
body.  Yet  the  integrity  of  these  organs  depends 
much  on  the  maintenance  of  a  healthy  vitality,  and 
this  on  that  of  the  general  system.  A  dead  tooth 
will  decay  far  more  rapidly  than  a  living  one  in  simi- 
lar circumstances ;  and  hence  the  conclusion  that 
vitality  resists  injurious  agents,  and  that  the  resist- 
ance will  be  in  proportion  to  the  vitality. 

All  febrile  conditions  promote  and  facilitate  decay, 
and  frequently  in  two  ways  :  by  diminishing  vitality, 
and  by  changing  the  secretions  of  the  mouth  so  that 
these  act  injuriously  upon  the  teeth.  Accompanying 
such  conditions  there  is  generally  inflammation  of  the 
dentine ;  and  in  such  cases  this  always  partakes  of 
the  general  disorder,  so  as  to  become  very  susceptible 
to  injury.  All  diseases,  indeed,  that  impair  the 
vitality  and  change  the  secretions,  may  be  considered 
predisposing  causes  of  decay,  and  some  even  more  ; 
dyspepsia,  for  instance,  being  not  only  predisposing, 
but  also  exciting,  since  it  prepares  in  the  stomach  an 
acid  that  is  almost  continually  thrown  upon  the  teeth, 
and  that  acts  upon  them  with  great  energy.     Resi- 


PREDISPOSING  CAUSES  OF  CARIES.  57 

dence  in  miasmatic  regions  is  also  a  predisposing 
cause,  inducing  unfavorable  conditions. 

Diminished  vitality  may  result  either  from  consti- 
tutional or  from  local  causes.  These  latter  are  such 
as  produce  an  irritable  or  diseased  condition  of  the 
contiguous  parts,  or  an  abnormal  condition  of  the  den- 
tine, Avithout  the  power  to  effect  its  decomposition. 
Local  causes  of  a  diminution  of  vitality  are  not  in 
their  character  so  formidable,  and  not  so  difficult  to 
control,  as  those  which  are  constitutional. 

Many  medicinal  agents  are  regarded  as  predispos- 
ing causes  of  caries ;  and  among  these,  mercurials 
occupy  a  prominent  place.  They  operate  by  vitiating 
the  secretions  of  the  mouth,  and  producing  an  abnor- 
mal condition  of  the  periosteum  about  the  roots  of 
teeth,  the  mucous  follicles,  and  the  salivary  glands. 
Some  entertain  the  opinion  that  the  abnormal  action 
of  the  absorbents  induced  by  mercurials  predisposes 
to  decay. 

Dental  operations  performed  at  an  improper  time, 
and  in  an  improper  manner,  may  be  reckoned  among 
the  predisposing  causes  of  caries.  The  vitality  of  the 
teeth  may  be  thus  impaired,  or  a  diseased  condition 
established,  or  the  part  operated  upon  may  be  per- 
mitted to  remain  rough,  so  that  foreign  substances 
will  be  retained,  and,  becoming  vitiated,  produce  a 
deleterious  effect.     Often,  from  an  improper  use  of 


58  CARIES    OF   THE    TEETH. 

the  file,  extensive  inflammation  of  the  dentine  super- 
venes, which  is  sometimes  followed  by  death  of  the 
tooth,  and  by  disease  of  the  contiguous  parts.  Arti- 
ficial substitutes,  imperfectly  adapted,  are  in  many 
instances  the  occasion  of  caries ;  not  that  clasps  or 
the  edges  of  the  plate  tend  directly  to  injure  the 
tooth,  but  the  agencies  superinduced  by  them  do, 
and  especially  when  the  material  used  is  not  of  the 
right  quality. 

Lack  of  proper  exercise  in  mastication  induces  a 
condition  favorable  to  decay,  both  by  favoring  the 
action  of  injurious  agents  upon  the  teeth  and  by  with- 
holding the  stimulus  of  normal  exercise.  Tartar  and 
other  deleterious  substances  are  much  more  rapidly 
deposited  when  the  teeth  are  idle. 

The  teeth  cannot  with  impunity  undergo  great 
and  sudden  transitions  of  temperature,  or  even  such 
variations  as  may  be  endured  by  the  surrounding 
parts.  By  these,  inflammation  of  the  dentine  may 
be  induced,  and  the  vitality  of  the  teeth  dimin- 
ished. And  in  friable  teeth,  checking  of  the  enamel 
may  occur,  and  thus  a  condition  arise  that  will  facili- 
tate decay. 


EXCITING    CAUSES    OF    CARIES.  59 

EXCITING    CAUSES   OF    CARIES. 

When  there  is  a  predisposition  to  caries,  any  of  the 
exciting  causes  act  with  more  effect.  Well-organized 
teeth,  of  unimpaired  health  and  vitality,  withstand 
influences  that  in  less  favorable  circumstances  des- 
troy them  in  a  very  short  time.  The  immediate 
cause  of  decay  is  the  action  of  agents  chemically  upon 
the  teeth.  It  is  not  here  proposed  to  enter  upon  an 
investigation  of  the  manner  in  which  these  various 
agents  operate,  for  that  would  open  up  a  large  field 
for  consideration — a  field  outside  of  the  province  of 
this  work.  The  sources  of  these,  however,  are  several : 
as,  vitiated  secretions  of  the  mouth ;  the  saliva,  and 
the  mucus ;  abnormal  secretion  from  the  stomach ; 
decomposition  of  animal  and  vegetable  substances  in 
the  mouth,  etc. 

The  natural  state  of  the  mucus  is  acid,  but  that  of 
the  saliva  alkaline ;  so  that  these  secretions  counter- 
act each  other ;  but  when  the  saliva  and  the  mucus 
jire  both  acid,  the  teeth  must  suffer.  These  secre- 
tions may  become  vitiated  through  inability  of  the 
glands,  from  disease  or  an  enfeebled  condition,  per- 
fectly to  perform  their  functions ;  or  the  blood  may 
be  in  an  abnormal  state,  and  the  glands  unable,  on 
that  account,  though  they  were  healthy, — as  they 
seldom  are  in  such  case, — to  elaborate  healthy  saliva. 


60  CARIES    OF   THE   TEETH. 

When  the  fountain  is  corrupt,  the  stream  cannot  be 
pure.  Thus,  anything  that  produces  a  diseased  con- 
dition of  the  blood  tends  to  the  decay  of  the  teeth ; 
and  such  diseased  condition  often  has  a  directly 
injurious  effect  on  the  secretive  apparatus,  and  so 
works  a  double  harm. 

But  to  the  theory  of  the  pernicious  influence  of  the 
saliva,  it  may  be  objected,  that  if  it  were  true,  all 
parts  of  the  teeth  would  be  alike  affected.  This 
objection,  however,  will  lose  its  force  when  it  is  con- 
sidered that  the  teeth,  in  many  cases,  are  not  equally 
well  organized  in  all  their  parts;  that  some  parts  are 
not  so  well  protected  as  others ;  and  that  between  the 
teeth  there  is  room  for  the  retention  of  saliva  and 
foreign  substances,  which  there  combine  their  influ- 
ence upon  them.  When  there  is  a  great  quantity  of 
viscid  saliva  constantly  flowing,  the  teeth  decay  very 
rapidly.  The  decay  is  of  a  light  color — so  light, 
indeed,  that  in  many  instances  it  is  difficult  to  dis- 
tinguish it,  by  this,  from  undecomposed  dentine. 

The  gastric  fluid  often  becomes  deranged  by  irrita- 
tion or  disease  of  the  stomach,  so  that  the  function 
of  the  latter  is  very  imperfectly  performed,  and  fer- 
mentation of  the  food  occurs,  evolving  agents  that 
injuriously  affect  the  teeth.  In  dyspepsia,  such 
agents  are  often  brought  in  contact  with  the  teeth  by 
eructation  and  vomiting;   and  the   diseased  gastric 


EXCITING   CAUSES    OF    CARIES.  61 

fluid,  w'hich  contains  a  large  proportion  of  hydro- 
chloric acid,  is  also  thus  brought  in  contact  with  them, 
acting  with  great  violence.  After  food  commingled 
with  this  secretion  is  ejected  from  the  stomach,  the 
teeth  will  be  found  eroded  over  all  their  surfaces. 
Dyspeptics  will  appreciate  this  remark.  In  such 
cases,  if  the  teeth  are  not  of  superior  organization, 
they  are  destroyed  in  a  short  time.  Their  surfaces, 
thus  roughened,  afford  a  lodgment  for  foreign  sub- 
stances on  all  parts. 

The  most  common  agents,  however,  that  injure 
the  teeth,  are  originated  in  the  mouth  by  the  decom- 
position of  animal  and  vegetable  matter.  By  this 
process,  elements  are  eliminated  that  form  new 
combinations,  and  these  operate  with  energy  in  the 
destruction  of  the  teeth.  Favorable  conditions  exist 
in  the  mouth  for  such  decomposition,  and  also  for 
such  new  combinations ;  for  there  is  a  sufficient 
amount  of  heat  and  moisture, — for  both  of  these, 
especially  the  former,  facilitate  the  action  of  any 
acid  upon  the  dentine.  The  character,  of  the  saliva 
and  mucus  will  very  much  modify  the  decomposition 
of  foreign  substances  in  the  mouth.  If  these  secre- 
tions are  both  acid,  the  decomposition  will  be  much 
more  rapid,  and  more  potent  in  its  effect. 

Again,  it  is  sometimes  the  case  that  the  salivary 
glands  are  comparatively  inactive,  except  when  spe- 


62  CARIES    OF   THE   TEETH. 

daily  excited,  and  yet  the  mucous  glands  still  effi- 
cient, eliminating  their  secretion ;  so  that  the  mouth 
assumes  an  acid  condition,  because  there  is  not  saliva 
sufficient  to  neutralize  the  mucus,  in  which  condition 
decomposition  of  foreign  substances  would  be  greatly 
accelerated.  There  are  many  cases,  however,  in 
which  the  flow  of  saliva  is  copious,  and  yet  the 
decay  very  rapid,  which  is  in  consequence  of  an 
acid  condition  of  both  secretions,  or  of  a  rapid 
decomposition  of  foreign  substances  in  the  mouth. 

There  are  acids  taken  with  the  food  that  act 
directly  upon  the  teeth ;  as  acetic  acid,  or  vinegar. 
Professor  Westcot  says  :  "  Acetic  and  citric  acids  so 
corroded  the  enamel  in  forty-eight  hours,  that  much 
of  it  was  easily  removed  with  the  finger-nail."  And 
"Malic  acid,  or  the  acid  of  apples,  in  its  concentrated 
state,  also  acts  promptly  upon  the  teeth."  Now, 
these  acids,  in  the  use  of  many  kinds  of  food,  are 
brought  into  frequent  contact  with  the  teeth.  In 
the  manufacture  of  vinegar,  sulphuric  acid  is  often 
employed ;  so  that  in  this  article  of  food  we  have 
that  acid  either  alone  or  combined  with  the  acetic, 
the  former  acting  with  greater  energy  upon  the  teeth 
than  the  latter.  Acetic  acid  also  facilitates  the  fer- 
mentation of  food  retained  in  the  mouth,  and  thus 
reproduces  itself  in  abundance. 

After  eating  apples  that  contain  a  great  amount  of 


EXCITING    CAUSES    OF    CARIES.  63 

malic  acid,  the  teeth  will  be  found  corroded  over  all 
their  surfaces.  This  acid,  as  well  as  the  others, 
affects  the  enamel  somewhat,  and  when  the  latter  is 
very  thin,  though  it  may  not  be  all  removed  from 
any  particular  point,  yet  its  integrity  will  be 
destroyed,  so  as  to  be  readily  fractured,  thus  admit- 
ting injurious  agents  to  contact  with  the  dentine, 
which  is  much  more  susceptible  of  injury  from  acids 
than  the  enamel :  points  imperfectly  protected  by 
this  are  violently  attacked  by  acetic,  malic,  and 
sulphuric  acids,  especially  when  in  the  nascent  state. 
In  decayed  cavities  these  agents  produce  rapid 
results.  They  should  be  as  much  as  possible  avoided, 
and,  when  necessarily  used,  should  be  removed  from 
the  teeth  by  cleaning  with  great  care.  It  would  be 
safest  to  employ  some  neutralizing  agent  after  the 
use  of  any  acids  with  food.  During  mastication, 
there  is  an  increased  secretion  of  saliva,  which,  if  in 
a  healthy  state,  will  tend  to  neutralize  an}^  acid  that 
may  at  the  time  be  present,  and  also,  by  its  flow,  to 
remove  foreign  substances  from  the  mouth. 

Salts  may  be  decomposed  in  the  mouth,  and  their 
acids  act  upon  the  teeth ;  as  when  the  acid  of  the 
salt  has  a  stronger  affinity  for  any  element  of  the 
tooth-bone  than  for  the  base  with  which  it  is  com- 
bined. Many  medical  preparations  contain  agents 
peculiarly  deleterious  to  the  teeth,  acids  being  espe- 


64  CARIES    OF   THE   TEETH. 

cially  in  requisition  for  these,  and  oftentimes  in 
considerable  quantities.  The  acids  most  commonly 
thus  administered  are  the  hydrochloric,  the  nitric, 
the  sulphuric,  the  acetic,  the  tartaric,  and  the  citric, 
any  one  of  Avhich  will  produce  direct  and  rapid 
corrosion  of  the  dentine,  even  when  unaided  by  the 
temperature  of  the  mouth.  For  a  fuller  and  more 
explicit  presentation  of  the  points  here  briefly  hinted 
at,  see  Appendix  at  the  close  of  this  volume.  Sec.  A. 
These  acids  are  often  administered  by  physicians 
without  any  regard  to  their  nature  or  their  influence 
upon  the  teeth.  Sometimes,  however,  they  are  given 
through  a  tube,  though  this  method  generally  does 
not  amount  to  much  as  a  precautionary  measure,  for 
in  most  instances  the  fluid  comes  in  contact  with  all 
parts  of  the  mouth.  A  subsequent  rinsing  of  the 
mouth  with  water  effects  only  a  dilution,  not  an 
entire  removal  of  the  acid.  In  order  wholly  to 
counteract  their  injurious  influence  upon  the  teeth, 
an  alkaline  solution  should  be  used  after  the  adminis- 
tration of  such  medicines. 

Galvanic  action  is  a  cause  of  decay  of  the  teeth, 
only  so  far  as  it  is  a  means  of  decomposing  com- 
pounds in  the  mouth,  and  the  elements  of  which, 
according  to  the  laws  of  aflinity,  form  other  com- 
pounds prejudicial  to  the  teeth.  The  elements 
hydrogen,  nitrogen,  and   oxygen,  may   thus  be  set 


EXCITING    CAUSES    OF   CARIES.  65 

free  from  animal  and  vegetable  substances,  ^Yhen 
they  will  at  once  seek  other  elements  with  which  to 
combine ;  and  the  character  of  the  combinations  will 
be  determined  by  the  nature  of  the  elements,  and  by 
the  attendant  circumstances.  These  compounds  will 
frequently  be  of  an  acid  character. 

Such  an  arrangement  may  exist  as  will  maintain 
a  constant  galvanic  action,  whose  legitimate  effects 
will  be  as  constant  upon  the  teeth ;  and  this  cease- 
less process  cannot  but  make  its  mark.  It  is  a 
favorable  arrangement  for  galvanic  action  when  there 
are  two  or  three  kinds  of  metals  in  the  mouth  at 
once,  particularly  if  these  are  such  as  differ  in  their 
affinities  for  oxygen,  and  in  their  electric  conditions. 
In  some  cases  three  or  four  kinds  of  metals  are 
employed  in  filling  teeth  of  the  same  mouth;  in 
some,  fillings  of  one  metal  and  a  plate  of  another ; 
and  in  others,  plates  of  so  low  a  carat  are  used  that 
they  oxydize  rapidly  in  the  mouth,  without  the  aid 
of  any  other  metal. 

COMPARATIVE    LIABILITY    TO   DECAY. 

All  classes  of  teeth  are  not  alike  liable  to  decay. 
Their  difference  in  this  respect  may  arise  from  a  dis- 
similarity in  their  organic  structure,  the  best  organized 
being  the  most  capable  of  resisting  disease ;  or  from 


66  CARIES    OF   THE   TEETH. 

a  concentration  of  the  destructive  agency  upon  the 
tooth  first  affected.  The  first  molars  are  much  more 
liable  to  decay  than  any  other  teeth,  since  they  are 
less  perfectly  developed  than  those  formed  at  a  later 
period  of  life.  They  are  the  first  permanent  teeth 
erupted,  and  are  subjected  to  all  the  irritating  condi- 
tions consequent  on  the  removal  of  the  temporary 
and  the  development  and  eruption  of  the  permanent 
teeth.  But  these  concUtions  in  many  cases  produce  no 
apparent  injury  upon  them,  they  maintaining  their 
integrity  till  all  the  other  permanent  teeth  appear, 
and  then  decaying  earlier  than  any  others.  In  such 
cases,  the  decay  is  a  result  of  influences  more  potent 
than  those  occurring  on  the  eruption  of  the  other 
teeth. 

After  the  first,  the  second  molars  are  most  subject 
to  caries ;  and  after  these  the  second  bicuspids.  The 
latter  two  classes  doubtless  are  so  subject,  more  from 
the  facility  they  afford  to  the  lodgment  of  deleterious 
substances  than  from  a  relatively  imperfect  organiza- 
tion. Besides,  from  six  to  fifteen  years  of  age,  the 
teeth  are  less  appreciated  and  less  cared  for  than  at 
a  later  period  of  life.  The  next  most  liable  to  decay 
are  the  third  molars.  Then  follow  in  order  the  first 
bicuspids,  the  lateral  incisors,  the  central  incisors,  and 
the  cuspids.  Herewith  are  appended,  in  tabular  form, 
one  thousand  cases  of  decayed  teeth,  as  observed 


i 


CONSEQUENCES   OF   CARIES.  67 

under  ordinary  circumstances,  exhibiting  the  number 
and  per  cent,  of  these  in  each  class  : — 

26,  or    2^  per  cent.,  in  central  incisors. 


28, 

or    3| 

in  lateral  incisors. 

2-1, 

or    2} 

in  canines. 

87, 

or    8f 

in  first  bicuspids. 

134, 

or  13J 

in  second  bicuspids 

370, 

or  37 

in  first  molars. 

218, 

or  22f 

in  second  molars. 

102, 

or  lOJ 

in  third  molars. 

Of  these,  a  large  proportion  were  removed  for  relief 
from  disease  originating  in  caries  of  the  dental  tissue. 
In  general,  the  superior  teeth  are  liable  to  decay 
earlier  and  more  rapidly  than  the  inferior. 

CONSEQUENCES   OF   CARIES. 

It  is  here  proposed  to  refer  only  to  some  of  the 
more  common  results  of  this  affection,  one  of  the  most 
obvious  of  which  is  the  exposure  of  the  pulp  of  the 
tooth,  on  which  exposure  disease  ensues,  and  finally 
death.  During  this  diseased  condition  of  the  pulp, 
there  occurs  that  very  peculiar  and  well-known  sen- 
sation commonly  denominated  toothache.  As  weU  as 
the  destruction  of  the  pulp,  the  entire  destruction  of 
the  crown  of  the  tooth  is  the  inevitable  consequence 
of  caries,  unless  arrested  in  its  progress.  After  the 
destruction  of  the  pulp  and  the  lining  membrane. 


G8  CARIES    OF   THE    TEETH, 

the  external  periosteum  in  many  cases  becomes 
involved,  the  affection  being  but  an  extension  of  that 
which  destroys  the  internal  periosteum.  Inflamma- 
tion and  suppuration  are  of  common  occurrence,  by 
which  a  discharge  is  established  from  between  the 
margin  of  the  gum  and  the  neck  of  the  tooth,  or 
through  a  fistulous  opening  in  the  process  and  the 
gum,  as  is  the  case  when  an  abscess  is  formed  at  the 
point  of  a  root. 

A  diseased  condition  of  the  alveolar  process  is  in 
many  instances  produced  by  diseased  and  dead  teeth, 
necrosis  and  exfoliation  of  considerable  portions  being 
sometimes  the  result.  Indeed,  extensive  caries  of 
the  jaw  is  occasionally  thus  produced.  Disease  of 
the  antrum,  too,  is  very  generally  induced  or  greatly 
aggravated  by  the  same  cause.  Tumors,  sometimes 
of  a  malignant  character,  connected  either  with  the 
bony  or  with  the  soft  parts,  not  unfrequently  spring 
from  this  source,  particularly  in  constitutions  of  a 
cancerous  diathesis.  Great  nervous  derangement  may 
result,  either  in  whole  or  in  part,  from  decayed  teeth, 
as  does  very  frequently  facial  neuralgia,  which  is 
sometimes  confined  to  a  single  nerve-branch  in  the 
immediate  vicinity  of  the  irritating  cause,  sometimes 
ramified  over  the  whole  side  of  the  face  and  head, 
and  occasionally  spreads  much  farther,  so  as  even  to 
implicate  the   shoulder  and  the  arm.     Neui^algia  of 


CONSEQUENCES    OF   CARIES.  69 

these,  extending  down  to  the  hand,  is  often  found  to 
be  instantly  relieved  by  extraction  of  a  diseased 
tooth;  and  any  operator  of  much  observation  can 
call  to  mind  numerous  instances  in  which  fticial  neu- 
ralgia has  been  thus  relieved  or  wholly  cured.  This 
affection  of  the  face,  however,  does  not  always  origi- 
nate in  diseased  teeth,  though  there  is  little  doubt 
that  in  a  majority  of  cases  it  arises  wholly  or  partially 
from  this  cause. 

Inflammation  of  the  mucous  membrane  of  the 
mouth  is  a  common  result  of  diseased  teeth;  and  it  is 
liable  to  extend  to  distant  parts  of  this  membrane, 
and  occasion  greater  difficulty  than  in  the  mouth,  as 
would  especially  be  the  case  when  there  is  an  irri- 
table condition  of  the  throat  and  bronchia ;  and  the 
esophagus  and  stomach  are  not  exempt.  In  what 
degree  such  an  implication  of  the  respiratory  and  the 
digestive  apparatus  is  referable  to  diseased  teeth,  it 
may  not  be  easy  to  determine ;  but  it  is  impossible 
that  a  number  of  such  teeth,  involving  in  their 
disease  all  the  ramifications  of  the  facial  nerves  and 
the  whole  mucous  membrane  of  the  mouth,  could 
remain  there  with  impunity.  And  besides  this  direct 
influence  on  the  lungs  and  stomach,  diseased  teeth 
are  constantly  emitting  offensive  odors,  which  are 
taken  in  by  inhalation,  and  offensive  matter,  which 
is  swallowed  with  the  food. 


70 


CARIES   OF   THE   TEETH. 


TREATMENT   OF    CARIES. 


In  the  rational  treatment  of  caries,  the  first  con- 
siderations are  the  nature  and  peculiarities  of  the 
obvious  predisposing  causes ;  whether  these  are  con- 
stitutional or  local;  and  if  constitutional,  whether 
they  are  such  as  can  be  modified  by  therapeutic 
treatment  of  the  general  system.  If  the  latter,  such 
treatment  should  be  adopted  as  will  bring  about  the 
most  perfect  state  of  health,  so  as  to  obviate  as  far  as 
possible  all  conditions  favorable  to  decay,  by  securing 
a  healthy  condition  of  the  mouth  in  all  its  parts — as 
the  gums,  the  mucous  membrane,  and  the  salivary 
glands.  The  teeth  should  be  kept  free  from  all 
deposits  and  accumulations  of  whatever  character ; 
for  though  some  of  these  may  not  affect  the  teeth 
directly,  yet  they  induce  disease  of  the  surrounding 
parts,  and  thus  indirectly  exert  a  pernicious  influence 
upon  them. 

The  foregoing  remarks,  however,  refer  rather  to 
the  prevention  of  decay  than  to  its  treatment  after  it 
actually  exists.  Yet  they  are  on  that  account  none 
the  less  important,  since  here,  as  elsewhere,  preven- 
tion is  better  than  remedy.  But  they  apply  to  such 
prevention  as  well  after  decay  has  commenced  as 
before,  if  the  ultimate  object  is  preservation  of  the 


TREATMENT    OF   CARIES.  71 

teeth.  After  the  first  attack,  the  teeth  are  more 
vulnerable,  and  less  capable  of  resistance. 

When  decay  has  attacked  a  tooth,  the  treatment 
indicated  depends  upon  the  nature  and  extent  of  the 
disease.  Rapid  decay  requires  more  prompt  and 
energetic  treatment  than  that  of  slow  progress. 
Remedies  appropriate  and  efficient  in  the  one  are 
quite  inapplicable  to  the  other.  The  persistence  of 
caries  is  not  always  in  proportion  to  its  rate  of 
progress.  We  sometimes  find  teeth  in  which  the 
decay  is  not  advancing  rapidly,  and  thence  are  led  to 
conclude  that  it  may  be  easily  arrested ;  the  affected 
part,  if  superficial,  is  easily  removed,  and  the  dentine 
thoroughly  polished;  and  yet,  after  a  time,  decay 
again  attacks  the  tooth  at  the  same  point.  Or,  where 
the  caries  has  penetrated  the  tooth,  so  that  it  requires 
filling,  though  it  is  skillfully  done,  and  the  plug  and 
tooth  carefully  polished,  yet  in  many  instances  the 
dentine  soon  softens  about  the  border  of  the  filling. 

The  extent  and  nature  of  the  decay  will  suggest 
the  mode  of  treatment.  Superficial  caries  on  some 
parts  of  the  teeth  may  be  remedied  and  removed  by 
cutting  away  the  portion  implicated  in  the  disease, 
dressing  with  a  fine  file,  polishing  with  Arkansas, 
Scotch,  or  rotten  stone  till  the  file  marks  disappear, 
and  then  applying  the  buff  with  rouge  or  oxyd  of 
tin  very  thoroughly  to  the  entire  surface  operated 


72  CARIES    OF   THE   TEETH. 

upon.  Afterward,  the  most  careful  attention  to 
cleanliness  is  requisite,  to  prevent  a  recurrence  of 
the  attack.  This  treatment  is  applicable  to  decay 
upon  proximal  surfaces ;  but  in  the  depressions  of 
the  masticatory  and  buccal  surfaces  of  the  molars,  it 
is  not  practicable. 

Sometimes  the  dentine,  at  points  where  it  is 
exposed,  gives  warning,  by  acute  sensitiveness,  of 
threatened  decomposition,  before  there  are  any  other 
indications  of  it,  thus  evidencing  the  presence  of 
some  very  irritating  agent  promotive  of  decay. 
Such  points  should  receive  prompt  and  strict  atten- 
tion, and  the  increased  sensitiveness  be  immediately 
subdued ;  as  it  may  be  by  the  use  of  some  prepara- 
tion that  will  counteract  the  exciting  influence — some 
dentifrice  or  lotion  containina:  an  alkali ;  or  rubbina: 
the  sensitive  surface  with  a  steel  burnisher  will  in 
many  cases  effect  this  object,  and  prevent  the 
development  of  decay.  Nitrate  of  silver  is  some- 
times used  for  this  purpose,  and  occasionally  proves 
very  efficient ;  but  its  general  use  for  such  cases  is 
of  doubtful  propriety,  and  when  used,  it  should  be 
with  discrimination  and  caution. 

It  has  been  suggested  that  the  character  of 
caries  may  be  modified  by  the  local  application  of 
therapeutic  agents — that  the  rapid  decay  may  be 
changed  to  the  slow,  and  this,  too,  without  regard 


TREATMENT    OF   CARIES.  7o 

to  the  attendant  circumstances,  such  as  the  condition 
of  the  secretions  of  the  mouth,  the  causes  producing 
the  disease,  etc.  For  this  purpose  various  agents 
have  been  proposed.  It  is  held  that  by  an  applica- 
tion of  the  nitrate  of  silver,  the  white,  rapid  decay 
being  changed  to  that  of  a  dark  color,  is  arrested  in 
its  progress.  But  there  is  no  very  palpable  principle 
on  which  this  agent  can  be  supposed  to  operate  to 
arrest  caries.  It  is  generally  conceded  to  be  injurious 
to  a  healthy  tooth ;  how,  then,  it  becomes  beneficial 
to  one  decayed,  it  is  not  easy  to  perceive.  The 
notion  may  have  originated  in  the  fact  that  after  the 
application  of  nitrate  of  silver,  the  dentine  to  which 
it  has  been  applied  turns  dark,  or  black ;  and  this 
color  being  naturally  associated  with  the  slow  form 
of  decay,  it  may  have  been  concluded  that  it  might 
be  thus  associated  by  artificial  means.  This  conclu- 
sion, however,  is  fallacious ;  for  the  coloring  matter 
being  the  oxyd  of  silver,  deposited  on  the  walls  of 
the  cavity,  is  wholly  foreign,  and  holds  no  necessary 
relation  to  the  kind  of  decay,  or  to  the  agent  pro- 
ducing it.  The  deposit  may  possibly  serve  as  a 
temporary  shield  to  the  dentine  beneath,  but  only 
temporary;  whereas,  on  the  other  hand,  it  will  be 
remembered  that  nitric  acid  is  liberated  by  the 
decomposition  of  the  nitrate,  and  operates  destruc- 
tively upon  the  tooth-bone.     An  ethereal  solution  of 


74  CARIES    OF   THE   TEETH. 

the  terchloride  of  gold  has  also  been  suggested  as  a 
preventive  application.  Its  operation  would  be  much 
the  same  as  that  of  the  nitrate  of  silver,  and  equally 
inefficient.  Preparations  to  neutralize  and  counteract 
the  effects  of  deleterious  agents  upon  the  teeth  have 
been  recommended  as  topical  applications.  These 
are  such  as  possess  alkaline  properties.  But  any- 
thing of  this  kind  would  require  frequent  application ; 
indeed,  it  would  be  necessary  to  keep  the  affected 
part  constantly  under  its  influence,  as  long  as  the 
surrounding  conditions  continued  to  favor  decay. 

Though  nothing  of  this  kind  can  be  relied  upon 
permanently  to  arrest  caries,  yet,  in  many  instances, 
much  benefit  is  to  be  derived  from  local  treatment. 
Alkaline  topical  applications  will  in  many  cases 
alleviate  the  most  acute  sensitiveness  of  the  dentine, 
accomplishing  this,  no  doubt,  by  their  neutralizing 
influence  upon  the  irritating  agents.  Many  opera- 
tors employ  simply  the  bicarbonate  of  soda  for  this 
purpose,  with  the  happiest  results.  As  another  class 
of  topical  applications  to  check  or  modify  caries, 
those  have  been  suggested  which  will  form  an  insol- 
uble compound  with  the  gelatinous  or  animal  portion 
of  the  tooth  ;  such  as  tannin,  creosote,  and  some  of 
the  essential  oils.  The  only  effect  of  these,  however, 
is  to  form  a  shield  or  protection  over  the  structure 
beneath  :  there  is,  of  course,  no  change  effected  in 
the  conditions  or  agents  which  produce  decay. 


CHAPTER  III. 

GENERAL  REMARKS  ON  FILLING. 

The  importance  and  value  of  the  operation  of 
filling  teeth  are  obvious,  from  various  considerations. 
It  is  one  that  is  in  frequent  requisition.  It  is  the 
only  treatment  for  deep-seated  caries.  By  it  the 
disease  is  arrested  and  the  lost  part  restored,  so  far, 
at  least,  as  it  can  be  by  a  foreign  substance.  There 
is  no  material  similar  to  that  destroyed — no  substance 
possessing  the  characteristics  of  the  lost  portion  of 
the  tooth,  with  which  to  effect  the  restoration.  Under 
favorable  circumstances,  the  operation  of  filling  is 
efficient  in  arresting  caries,  and  restoring,  to  a  greater 
or  less  extent,  the  lost  portion  of  the  tooth.  In 
order,  however,  that  it  be  permanent  in  its  character, 
the  case  needs  to  be  attended  with  favorable  condi- 
tions, and  the  work  to  be  thoroughly  done.  But 
two  similar  operations,  both  equally  well  performed, 
may  result  very  differently  as  to  ultimate  success  in 
preserving  the  teeth  to  which  they  may  have  been 
apphed;  the  one  effectually  preventing  further  decay, 
and  the  other  seeming  to  interpose  to  it  but  little 


76  GENERAL    REMARKS    ON    FILLING. 

obstacle.  Indeed,  the  probabilities  of  such  success 
in  different  operations,  equally  well  accomplished, 
cannot  be  calculated  without  considerinoj  a  variety 
of  circumstances,  such  as  differences  in  constitutions, 
in  states  of  health,  in  previous  and  subsequent  habits. 

Filling  teeth  is  predicated  upon  the  nature  of 
decay,  upon  the  fact  that  the  lost  portion  will  not  be 
restored  by  nature,  and  upon  the  fact  that  caries  is 
an  effect  of  external  causes,  and  not  of  any  cause 
within  the  tooth  itself.  If  the  causes  of  caries  were 
alone  within  the  tooth,  then  filling  would  not  be  its 
rational  treatment.  The  organic  structure  of  the 
teeth  is  of  such  nature  that  no  change  to  the  extent 
of  decomposition  will  take  place  in  it  independently 
of  external  influences.  Any  organ  or  structure  sus- 
ceptible of  becoming  diseased  by  any  cause  resident 
within  it,  usually  possesses  the  power  of  recupera- 
tion, and,  in  many  instances,  that  of  restoration  also; 
and  if  dentine  could  be  decomposed  without  external 
agents,  the  introduction  of  any  foreign  substance 
whatever  into  the  cavity  would  certainly  not  arrest 
the  decay,  but  most  probably  accelerate  it.  If  it  is 
true  that  decay  of  the  teeth  ever  originates  in  con- 
stitutional causes  alone,  then  the  treatment  should 
be  constitutional,  and  not  local. 

Filling  teeth,  then,  is  based  upon  the  inability  even 
of  healthy  dentine  to  prevent  the  occurrence  of  decay. 


GENERAL    REMARKS    ON    FILLING.  77 

As  preliminary  to  the  operation,  all  the  circumstances, 
both  direct  and  collateral,  should  be  carefully  noted 
in  every  case,  and  the  course  of  treatment  should 
conform  to  the  indications  thus  observed.  The  con- 
stitution, temperament,  and  health  of  the  patient; 
the  peculiarities  of  the  teeth ;  their  susceptibility  of 
decay ;  their  present  condition,  and  that  of  the  parts 
about  them ;  the  periosteum,  the  gums,  the  mucous 
membrane,  the  secretions  of  the  mouth,  the  saliva, 
and  the  mucus,  should  all  be  closely  considered ;  for 
only  on  a  correct  diagnosis  can  a  proper  treatment  be 
based.  Every  operation  should  be  performed  as 
completely  as,  under  the  circumstances,  it  is  possible. 
Indeed,  every  step  in  the  operation  should  be  perfect, 
before  a  succeeding  one  is  attempted.  All  the  instru- 
ments employed  should  be  unexceptionable  in  mate- 
rial, form,  and  condition ;  inferior  instruments  should 
find  no  place  in  the  case  of  the  dental  operator.  The 
material  for  filling  should  be  of  the  best  quality,  and 
prepared  in  the  best  possible  manner.  Not  that 
material  for  filling  should  be  prepared  in  only  one 
way ;  for  some  materials,  gold,  for  instance,  may  be 
prepared  in  three  or  four  different  forms,  each  perfect 
in  its  kind,  and  efficient  in  the  hands  of  the  expert 
manipulator.  While  with  instruments  and  materials 
all  in  the  most  perfect  condition,  and  with  a  thorough 
cognizance  and  appreciation  of  all  the  attendant  cir- 


78  GENERAL   REMARKS    ON    FILLING. 

cumstances,  our  most  skillful  operators  barely  attain 
success,  need  we  be  astonished  that  the  man  ignorant 
of  all  these  circumstances,  and  possessed  of  only  a 
few  crude,  ill-conditioned  instruments  and  materials, 
the  nature  of  which  he  does  not  understand,  fails  in 
almost  every  attempt  ? 

Much  depends  on  therapeutic  treatment ;  not,  in- 
deed, to  restore  parts  already  lost,  or  to  restore  to 
health  parts  much  diseased,  but  to  avert  a  tendency 
to  disease  in  parts  but  feebly  organized.  This  treat- 
ment may  be  either  constitutional  or  local,  or  both ; 
but  constitutional  when  there  is  indicated  any  idio- 
syncrasy favorable  to  decay.  If,  however,  the  whole 
difficulty  is  local,  topical  treatment  only  is  required. 
What  the  special  treatment  should  be  in  either  case 
will  be  more  fully  considered  hereafter.  Compara- 
tively little  can  be  accomplished  by  local  application 
to  the  substance  of  the  tooth ;  but  the  parts  contigu- 
ous, as  the  gums  and  the  mucous  membrane,  may  be 
thus  treated,  with  an  assurance  of  more  signal  results. 

Though  in  the  teeth  nature  does  not  assist  to  re- 
store a  lost  portion,  as  in  those  parts  more  highly 
organized,  yet,  to  compensate  in  some  degree,  the 
destructive  process  is  far  less  rapid  in  the  former  than 
in  the  latter.  The  general  surgeon  depends  much 
upon  nature  for  the  success  of  his  operations ;  for, 
though  he  performed  them  unskillfuUy,  yet  the  kind 


MATERIALS   FOR   FILLING.  79 

energy  of  nature  is  always  present  to  assist  him ; 
but  in  this  specialty  the  practitioner  must  necessarily 
depend  more  upon  his  skill,  and  less  upon  the  cura- 
tive efforts  of  nature ;  though  much  more  reliance  is 
placed  upon  it  now  than  formerly. 

MATERIALS    FOR    FILLING. 

In  the  selection  of  materials  for  filling  teeth,  there 
are  some  important  considerations  that  should  be 
kept  constantly  in  view;  the  first  and  principal  of 
which  is  to  choose  that  kind  which  will  protect  the 
tooth  from  further  decay — protect  the  affected  part 
against  the  influence  of  those  agencies  on  which  the 
disease  depends.  A  material  or  class  of  materials 
should  be  selected  that  would  not,  under  any  cir- 
cumstances, induce  either  a  local  or  a  constitutional 
injury. 

There  are  several  properties  that  materials  for 
filling  teeth  should  possess,  one  of  the  most  import- 
ant of  which  is, 

Indedructibility . — Any  substance,  whether  simple 
or  compound,  that  will  not  maintain  its  identity  and 
integrity  when  subjected  to  any  conditions  of  the 
mouth,  is  wholly  unfit  to  be  used  as  a  material  for 
filling.  If  compounds  are  employed,  they  should  be 
such  as  would  not  be  affected  by  the  secretions  of  the 


80  GENERAL    REMARKS    ON   FILLING. 

mouth,  or  by  any  attendant  conditions.  A  mere 
mechanical  mixture  would  not  be  an  appropriate 
material  for  permanent  filling ;  and  all  compounds  of 
the  metals,  so  far  as  we  are  familiar  with  them,  are 
unfit  for  this  purpose,  by  reason  of  the  facility  with 
which  they  are  changed  in  the  mouth.  The  next 
most  important  property  of  a  material  for  filling  is, 

AdaptaUliti/ . — By  which  is  meant  a  capability  of 
being  wrought  into  suitable  shapes  for  the  purpose, — 
a  facility  of  being  applied  and  conformed  to  the  parts 
upon  which  it  is  to  be  placed.  There  are  substances 
that  would  be  entirely  indestructible  in  the  mouth, 
and  that  would  be  very  desirable  in  other  respects  as 
materials  for  filling,  that  are  yet  altogether  worth- 
less for  this  purpose,  from  lack  of  adaptability. 
Quartz,  if  it  possessed  this  property,  would  be  valu- 
able as  a  material ;  but  as  yet  there  has  been  dis- 
covered no  method  of  preparing  it  in  an  available 
form.  On  the  other  hand,  many  things  possess  the 
property  of  adaptability  that  are  lacking  in  some 
other  important  particulars.  The  next  important 
property  is, 

Hardness. — A  material  may  possess  all  the  other 
suitable  qualities,  and  yet  be  too  soft.  A  material 
should  be  hard  enough  not  to  be  broken  or  worn 
away  by  any  pressure  or  friction  liable  to  be  applied. 
This  property  is  especially  desirable  for  fillings  in  the 


MATERIALS    FOR    FILLING.  81 

masticatory  surfaces  of  the  molars  and  bicuspids. 
It  would,  however,  be  admissible  to  employ  a  softer 
material  for  filling  cavities  in  the  proximal  surfaces 
of  the  teeth,  provided  it  would  perfectly  exclude  all 
foreign  substances. 

Non-conductor. — Again,  a  material  should  be  as 
nearly  as  possible  a  non-conductor  of  heat,  particularly 
for  filling  sensitive  teeth,  or  those  liable  to  become 
so  under  the  influence  of  slight  causes.  Great  A^aria- 
tions  of  temperature  will  in  most  instances  aggravate 
sensitiveness,  and,  in  susceptible  cases,  produce  it ; 
and  if  the  irritation  is  continued,  the  result  may  be 
necrosis.  Gold,  which  possesses  the  largest  number 
of  desirable  fjualities  as  a  material  for  filling,  is  in 
this  respect  very  defective,  being  one  of  the  best 
conductors  of  heat.  To  obviate  this  defect,  some 
non-conducting  material  may  be  employed  between 
the  gold  and  the  sensitive  portion  of  the  tooth.  The 
pulp  is  liable  to  be  affected  by  sudden  and  great 
changes  of  teniperature,  transmitted  to  it  through  a 
gold  plug. 

Cohesion. — In  the  next  place,  a  material  should  be 
susceptible  of  being  welded  or  united  into  a  solid 
mass.  The  permanency  of  an  operation  depends  very 
much  upon  this  quality.  A  filling  having  the  differ- 
ent pieces  which  compose  it  perfectly  united,  will  be 
much  more  durable  than  if  effected  with  a  material 


82  GENERAL    REMARKS    ON    FILLING. 

in  which  this  cohesive  property  is  lacking,  it  can  be 
made  with  greater  facility,  and  will  be  better  and 
longer  retained;  and  mainly  because  such  a  filling 
cannot  be  destroyed  piecemeal.  Non-cohesive  mate- 
rial is  retained  by  the  general  form  of  the  cavity, 
which  is  to  be  shaped  so  as  to  bind  all  the  pieces 
together,  and  thus  hold  them  in  place ;  but  a  sub- 
stance that  will  weld  requires  only  two  or  three 
good  retaining  points,  angles,  or  pits,  properly 
situated,  in  order  to  be  firmly  and  permanently  fixed 
in  a  cavity  of  any  form. 

Color. — Another  desirable  property  of  material  for 
filling  is  such  a  color  as  shall  best  harmonize  with 
that  of  the  teeth,  particularly  if  they  are  in  front.  In 
this  respect  all  the  metals  are  objectionable,  though 
gold  is  probably  less  so  than  any  of  the  others,  the 
objection  to  this  being  not  so  much  in  its  color  as  in 
its  luster;  which  objection,  however,  may  be  partially 
obviated  by  the  kind  of  finish  given  to  the  work.  In 
teeth  of  certain  shades — semi-transparent  bluish- 
white,  for  instance — gold,  for  exposed  fdlings,  is  very 
objectionable,  indeed,  in  some  cases,  almost  as  un- 
sightly as  the  absence  of  the  tooth ;  and  in  such 
instances,  the  darker  metals  would  of  course  appear 
much  worse.  For  such  teeth,  some  mineral  sub- 
stances, having  more  nearly  the  color  of  the  teeth, 
would  be  the  most  desirable. 


MATERIALS    FOR    FILLIXG,  83 

Most  of  the  materials  employed  for  filling  are  metal- 
lic ;  only  a  few  non-metallic  substances  have  been 
used,  and  these  rather  by  way  of  experiment,  and  for 
temporary  purposes,  than  with  any  hope  of  permanent 
results.  Of  the  metals,  gold  possesses  more  of  the 
indispensable  properties  than  any  other ;  but  the  fol- 
lowing have  been  used  for  filling :  lead,  tin,  silver, 
platinum,  gold,  and  amalgam.  In  the  preparation 
of  the  latter,  gold,  silver,  platinum,  tin,  bismuth, 
antimony,  cadium,  zinc,  and  mercury,  have  been 
employed. 

Lead. — This  metal,  in  the  early  history  of  the 
profession,  was  used  to  some  extent  for  filling  teeth, 
though  it  possesses  but  few  of  the  requisites  for  that 
purpose.  The  principal  quality  which  recommended 
it  is  its  adaptability ;  but  it  is  quite  too  soft  for 
permanent  fillings  in  the  masticating  surfaces  of  the 
molars.  It  is  easily  wrought  into  foil  and  welded 
into  mass  in  the  cavity,  but  it  is  rapidly  worn  down 
by  mastication,  and  its  integrity  readily  impaired 
by  the  influence  of  some  conditions  of  the  mouth ; 
much  more  readily,  indeed,  than  that  of  tin  or  silver. 
Acetic  and  some  other  acids  act  upon  it  with  con- 
siderable energy  in  the  mouth.  By  exposure  to  air 
and  moisture,  it  is  soon  coated  with  carbonate  or 
protoxyd  of  lead ;  and  this  change  is  effected  much 
more  readily  in  the  mouth.     Lead  is  also  objection- 


84  GENERAL    REMARKS    ON    FILLING. 

able  in  color,  especially  for  fillings  in  the  anterior 
teeth,  it  being  darker  than  the  other  metals  employed 
for  the  purpose.  It  is,  however,  a  less  perfect  con- 
ductor of  heat  than  some  others  that  are  in  for  more 
extensive  use. 

Tin. — This  metal  has  been,  and  is  even  yet,  much 
employed  as  a  material  for  filling.  It  is  easil^^ 
wrought  into  foil,  and  in  that  condition  is  readily 
adapted  to  the  purpose,  by  reason  of  its  softness  and 
pliability.  Fillings  can  be  made  with  it  in  all  cases 
in  which  non-cohesive  gold  foil  can  be  used,  to  much 
of  which,  indeed,  it  can  by  skillful  manipulation  be 
made  superior  in  cohesive  property.  Its  quality, 
however,  is  greatly  dependent  on  the  manner  of  its 
manufacture.  It  is  harder  than  lead,  and  in  many 
cases  hard  enough  for  permanent  fillings ;  it  is  fre- 
quently retained  in  crown  cavities  of  the  molars, 
effectually  preserving  the  teeth  for  many  years.  In 
favorable  conditions  of  the  mouth,  it  is  not  materially 
changed,  not  oxydizing  easily,  and  not  readily  uniting 
with  any  substances  liable  to  be  brought  in  contact 
with  it.  But  in  an  unhealthy  mouth,  with  the  secre- 
tions in  an  abnormal  condition,  and  the  teeth  neg- 
lected, tin  fillings  are  very  rapidly  destroyed  by  the 
action  of  nitric  or  hydrochloric  acid.  Such  a  change 
may  take  place  in  the  mouth  as  will  in  a  little  time 
destroy  tin  fillings  that  had  long  remained  in  good 


MATERIALS    FOR    FILLING.  85 

preservation ;  and  hence  this  material  is  not  entirely 
reliable  in  any  case,  since  such  change  may  at  any 
time  occur.  Some  cases  seemingly  favorable  to  its 
use  are  found,  on  examination,  to  be  otherwise;  and 
in  almost  any  mouth  in  which  there  is  a  large  pro- 
portion of  mucus  secreted,  it  cannot  be  depended 
upon  for  permanency.  Its  color  renders  it  unfit  for 
the  anterior  teeth.  It  is  a  less  perfect  conductor  of 
heat  than  gold,  on  which  account  it  is  frequently 
employed  where  the  latter  metal  can  not  be.  It 
should  not  be  used  in  a  tooth  in  which  there  is 
another  metal ;  notwithstanding  some  dentists  do 
sometimes  use  it  to  fill  the  interior  of  large  cavities, 
placing  upon  it  a  covering  of  gold.  This  method  is 
objectionable  in  two  particulars :  first,  the  tin  is 
softer  than  the  gold,  and  under  much  pressure  yields 
beneath  it,  so  as  to  destroy  the  integrity  of  the 
filling;  and  second,  when  the  fluids  of  the  mouth 
come  in  contact  with  the  two  metals,  a  chemical 
action  is  induced,  by  which  the  tin  is  rapidly 
corroded.  It  is  for  this  reason  that  no  two  metals 
should  be  applied  to  the  same  tooth;  as,  for  instance, 
tin  for  filling  a  tooth  round  which  there  is  a  gold 
clasp,  or  in  contact  with  which  is  a  gold  plate. 
Finally,  the  use  of  this  material  should  be  deter- 
mined not  only  by  all  these  circumstances,  but  also 
by  the   constitutional   predisposition  of  the  patient 


86  GENERAL    REMARKS    ON   FILLING. 

and  the  character  of  the  teeth,  which  shoukl  be 
dense  and  well  organized,  in  order  to  render  it  at  all 
admissible.  It  is  frequently  very  valuable  for  filling 
the  temporary  teeth,  and  for  temporary  use  in  the 
permanent  teeth. 

Silver. — This  metal,  in  the  form  of  foil,  has  never 
been  used  for  filling  teeth  except  experimentally. 
It  is  not  for  this  purpose  superior  to  tin  in  any 
particular,  except  in  being  somewhat  harder;  and  in 
some  particulars  it  is  inferior,  being  quite  as  destruc- 
tible in  the  mouth ;  more  easOy  affected  by  certain 
agents,  such  as  nitric  acid,  nascent  chlorine,  etc. ; 
less  pliable  and  less  adaptable ;  more  difficult  to  work 
into  foil;  not  so  readily  formed  into  fillings;  and 
possessed  of  much  less  cohesiveness,  being  almost 
unweldable  by  the  ordinary  method  of  manipulation. 
Silver  is  a  better  conductor  than  tin,  and  would 
therefore  in  many  cases  be  more  objectionable.  The 
saliva  is  often  in  such  a  condition  as  to  act  upon  it 
with  rapidity.  Its  color,  too,  is  objectionable.  Having 
these  disadvantages,  its  use  has  very  properly  never 
been  adopted. 

Platinum. — This  metal  has  been  but  little  used  for 
the  purpose  of  filling,  though  it  possesses  some  of 
the  requisite  qualities  in  a  very  high  degree ;  as,  for 
instance,  indestructibility,  in  which  property  it  is 
superior  to  gold.     In  other  respects,  however,  it  is 


MATERIALS    FOR    FILLING.  87 

very  deficient ;  it  has  not  as  yet  been  wrought  into 
any  form  in  wliich  it  can  be  welded  with  facility;  it  is 
difficult  to  work  into  foil,  and  when  it  is  put  into  this 
form,  it  possesses  a  stiffness  and  harshness  that  ren- 
der its  adaptation  and  condensation  almost  impracti- 
cable. It  is  more  on  this  account,  perhaps,  than  on 
any  other,  that  it  has  been  so  little  employed  for  the 
purpose  of  filling.  It  has  also  less  cohesiveness  than 
gold,  and  much  sooner  parts  with  this  property.  Slight 
crumpling  or  bending  serves  to  stiffen  it,  so  as  to 
destroy  its  applicability.  Good  fillings  may  be  made 
of  well-prepared  platinum  sponge,  recently  annealed. 
It  requires  skillful  manipulation,  however,  for  the 
least  moisture  destroys  its  cohesive  property  entirely. 
It  is  a  good  conductor  of  heat,  and  on  this  account 
objectionable.  In  the  respect  of  color,  too,  it  is  unde- 
sirable. Platinum  should  never  be  placed  in  close 
proximity  to  tin  fillings,  or  to  gold  plate  or  clasps  of 
low  carat.  It  is,  however,  being  employed  to  some 
extent  in  connection  with  gold,  which  in  some  respects 
seems  to  serve  a  valuable  purpose.  It  is  used  in  the 
form  of  foil,  of  any  desired  thickness,  heavily  coated 
with  pure  gold.  The  claims  for  this  combination 
are,  that  a  far  harder  and  more  resistant  filling  can 
be  made  than  with  gold  alone,  and  a  modification  of 
the  color  of  the  gold  that  is  far  preferable  for  teeth 
of  certain  shades  of  color. 


88  GENERAL    REMARKS    ON    FILLING. 

Gold. — Of  all  the  metals  that  have  as  yet  been 
used  for  filling  teeth,  gold  possesses  more  of  the 
requisite  jDroperties  than  any  other,  and  sufficiently 
so  for  all  practical  purposes.  Twenty-carat  gold  is 
very  seldom  affected  by  any  agencies  with  which  it 
is  brought  in  contact  in  the  mouth ;  pure  gold  never. 
In  the  filling  of  teeth,  there  are  two  objects  to  be 
aimed  at :  one,  a  sufficient  hardness  to  withstand  the 
wear  of  mastication ;  the  other,  a  thorough  protection 
to  the  cavity  against  all  decay-producing  agents.  For 
the  attainment  of  the  first  of  these,  gold  is  not  all 
that  could  be  desired ;  yet  it  is,  perhaps,  as  efficient 
in  this  respect  as  any  other  metal  that  can  be  em- 
ployed. But  the  second  object,  gold,  when  well 
manipulated,  accomplishes  very  effectually :  that  is, 
so  long  as  the  filling  maintains  its  integrity ;  after  it 
is  partially  worn  out,  it  thus  far  fails,  of  course.  In 
adaptability,  too,  gold  is  superior  to  any  other  metal. 
It  can  be  wrought  into  a  variety  of  forms,  with  any 
of  which  very  good  fillings  can  be  made.  It  can  be 
perfectly  conformed  to  any  shape  of  surface,  however 
irregular.  A  tooth  that  can  be  filled  at  all,  can  be 
filled  with  gold.  This  assertion  was  made  a  number 
of  years  ago ;  and  if  it  was  true  then,  it  is  much 
more  true  now ;  for  then  the  cohesive  property  of 
gold  was  not  employed  at  all,  or  even  recognized  as 
available ;  but  now,  this  property  has  been  rendered 


MATERIALS    FOR    FILLING.  89 

efficient  and  practicable.  Then,  our  best  operators 
did  not  aim  to  unite  the  different  portions  of  gold  of 
which  the  fillings  were  composed.  The  idea  that 
such  consolidation  could  be  effected  seemed  never  to 
have  entered  the  mind  of  any  one.  Indeed,  with  the 
instruments  and  the  method  of  manipulation  then 
employed,  this  cohesive  property  could  not  have  been 
made  available ;  but  as  it  came  to  be  recognized,  the 
instruments  and  the  manipulations  were  adapted  to 
the  purpose.  Formerly,  an  ordinary  gold  plug  wdien 
removed  from  a  cavity  could  be  readily  separated 
into  as  many  pieces  as  originally  composed  it ;  but 
now,  when  cohesive  gold  is  skillfully  used,  the  mass 
composing  a  filling  can  not  be  divided  into  its  original 
parts,  but  may  be  wrought  into  plate,  wire,  or  foil. 
Non-cohesive  gold — the  modification  in  which,  till 
about  the  year  1859,  it  was  always  employed — would 
not  weld,  even  under  great  pressure  ;  but  in  the  mode 
in  which  it  is  now  prepared,  it  will  w^eld  readily  and 
thoroughly.  There  are  certain  requisites  essential  to 
this  wielding  property  of  gold.  If  it  is  in  the  form  of 
foil,  it  should  not  present  a  smooth,  planished  surface ; 
it  must  be  annealed  after  hammering,  in  order  that 
its  ultimate  particles  may  be  in  the  best  condition  for 
cohering ;  it  must  be  entirely  free  from  all  deposits 
of  foreign  substances ;  and  it  must  be  kept  from  ex- 
posure to  the  atmosphere. 


90  GENERAL    REMARKS    ON    FILLING. 

Gold  is  a  good  conductor  of  lieat ;  and  this  is  the 
chief  objection  to  it  as  a  material  for  filling.  As  to 
sensitive  teeth,  this  is  a  very  serious  objection,  in 
some  cases  necessitating  the  employment  of  non- 
conducting material  beneath  it,  and  in  others  preclud- 
ing its  use  altogether.  The  color  of  gold,  however, 
is  seldom  an  objection  to  its  use,  though  it  sometimes 
renders  it  unsuitable  for  fillings  in  the  front  teeth. 
But  this  objection  has  been  already  adverted  to. 

Various  Prejjarations  of  Gold. — And  first,  of  the 
manufacture  of  gold  foil.  For  this  purpose  pure 
gold  is  used,  for  procuring  which  various  methods 
are  employed.  But  the  most  common  of  these  are 
insufficient  for  the  production  of  gold  absolutely  pure. 
It  is,  however,  deemed  irrelevant  here  to  detail  the 
process  by  which  this  end  is  attained  :  it  is  enough  to 
premise  that,  for  the  manufacture  of  the  best  quality 
of  foil,  pure  gold  is  indispensable.  The  gold  is  cast 
into  an  ingot  about  an  inch  wide,  is  then  placed 
between  a  pair  of  rollers,  and  milled  down  as  thin  as 
practicable,  the  piece,  Avhile  in  this  process,  being 
frequently  annealed.  It  is  then  cut  into  squares, 
which  are  inserted  with  wooden  pliers  between  vel- 
lum leaves,  a  hundred  and  sixty  or  seventy  in  a 
pack.  Over  this  pack  two  pockets  are  drawn,  inclos- 
ing it  completely.  The  pack  is  then  hammered  on  a 
granite  block,  with   a  hammer  weighing  twelve  or 


MATERIALS    FOR    FILLING.  91 

sixteen  pounds,  till  the  leaves  are  spread  out  to  the 
full  extent  of  the  pack.  They  are  then  removed 
from  the  pack,  cut  into  four  sections,  annealed,  re- 
placed in  the  pack,  and  again  subjected  to  the  ham- 
mer ;  this  process  is  repeated  till  the  desired  thick- 
ness of  foil  is  obtained.  Much  experience  and  skill 
are  requisite  to  the  proper  accomplishment  of  this 
part  of  the  work.  By  a  single  unskillful  stroke  of 
the  hammer,  a  whole  pack  may  be  spoiled. 

Gold  foil  is  numbered  according  to  the  graibs  con- 
tained in  each  leaf,  ranging  from  2  to  240.  The  most 
common  numbers  are,  2,  4,  6, 10,  20,  30,  60,  120,  and 
240 — the  latter  seldom  used ;  of  the  smaller  num- 
bers, 4  and  0  are  in  most  frequent  use.  It  has 
heretofore  been  a  desideratum  to  obtain  gold  foil  per- 
fectly uniform  in  quality.  This  seems  now  to  be 
almost  if  not  altogether  attained  by  the  most  careful 
and  skillful  manufacturers. 

Crystal  Gold. — This  form  of  gold  was  introduced 
to  the  profession  about  twenty-two  years  ago.  Some 
experiments  in  this  direction,  indeed,  had  been  made 
as  early  as  1825,  by  C.  Ash,  of  London,  and  again  in 
1850,  by  Dr.  S.  A.  Main,  of  New  York.  Their  pre- 
parations, however,  were  simply  precipitates,  and 
nothing  more.  But  in  1853,  Dr.  A.  J.  Watts,  of 
Utica,  New  York,  obtained  letters  patent  for  this  pre- 
paration of  gold  for  filling  teeth.     This  preparation 


92  GENERAL    REMARKS    ON    FILLING. 

was  at  first  denominated  sponge  gold,  but  after  some 
modification,  received  its  present  name.  There  are 
numerous  formulas  by  which  preparations  of  crystal 
gold  may  be  made ;  but  so  far  as  we  are  acquainted 
with  them,  they  are  all  embraced  in  two  general 
methods :  the  one,  to  obtain  simply  a  precipitate  of 
the  metal  adaptable  to  the  filling  of  teeth ;  and  the 
other,  to  combine  this  precipitate  with  mercury, 
and  obtain  a  definite  crystallization.  For  the  prepa- 
ration of  the  sponge  or  crystal  gold,  the  absolutely 
pure  metal  is  required.  This  is  dissolved  in  nitro- 
muriatic  acid,  the  gold  being  added  till  the  solution 
is  saturated.  Various  materials  may  be  used  to  pre- 
cipitate it,  the  most  common  of  which  are  sulphate  of 
iron  and  oxalic  acid,  the  latter  on  some  accounts 
being  preferable.  The  character  of  the  precipitate 
will  be  determined,  in  a  great  degree,  by  the  manner 
in  which  the  precipitant  is  added :  if  slowly,  the  pre- 
cipitate will  take  a  more  definite  form,  inclining  to 
the  crystalline  or  fibrous. 

A  preparation  may  be  made  by  introducing  the 
precipitant  gradually,  and  then  carefully  washing  the 
precipitate,  and  heating  almost  to  redness.  For  per- 
fect crystallization  of  the  gold,  combine  the  precipi- 
tate with  from  six  to  twelve  times  its  weight  of  pure 
mercury ;  let  it  stand  a  short  time,  subject  to  a  gentle 
heat,  and  then  remove  the  mercury  with  dilute  nitric 


MATERIALS   FOR    FILLING.  93 

acid.  Afterward  wash  the  nitrate  of  mercury  from 
the  gold ;  place  the  latter  upon  a  slide,  and  bring  it 
up  to  a  full  red  heat  in  a  muffle,  and  the  gold  is 
then  in  a  condition  to  be  used  for  filling.  This  is 
about  the  formula  on  which  a  patent  was  granted  to 
A.  J.  Watts.  The  preparation  possesses  some  advan- 
tages over  gold  foil.  It  is  as  readily  introduced ;  it 
is  more  capable  of  thorough  consolidation;  it  has, 
besides  the  cohesiveness  of  foil,  the  additional  prop- 
erty of  interlacing  its  crystals  one  with  another,  by 
which  property,  even  without  cohesion,  the  pieces  of 
a  filling  can  be  firmly  united ;  and  it  takes  a  better 
hold  upon  the  walls  of  the  cavity,  to  which  it 
presents  the  angles  and  ends  of  the  crystals,  so  as 
to  be  more  thoroughly  adapted  and  fa;stened. 

Amalgam. — By  this  term  are  designated  all  those 
preparations  formed  by  a  combination  of  mercury 
with  various  other  metals ;  most  frequently  with  sil- 
ver and  tin,  but  occasionally  with  gold,  platinum, 
bismuth,  cadmium,  zinc,  and  lead.  The  several  for- 
mulas for  amalgam  need  not  here  be  specified.  The 
kind  most  in  use  is  prepared  by  melting  together  and 
carefully  mixing  pure  tin  and  silver,  filing  this  mix- 
ture, when  cooled,  into  dust,  combining  the  latter 
with  mercury  in  sufficient  proportion  to  give  the 
requisite  plasticity,  and  then  thoroughly  washing  the 
whole  in  alcohol   or   boiling  water,   to   remove    the 


94  GENERAL   REMARKS   ON   FILLING. 

oxvtls  formed  diirinff  the  combination  of  the  metals. 
If  there  is  a  redundance  of  mercury,  it  may  be 
removed  by  pressing  the  paste  in  a  piece  of  chamois 
skin.  This  preparation  may  in  some  cases  be  used 
for  filling  with  considerable  success ;  but  in  no  case 
can  it  be  relied  upon  as  a  durable  material,  its 
destructibility  being  no  less  than  that  of  tin  or  silver 
in  any  circumstances,  and  being  greater  where  all  the 
excess  of  mercury  is  not  removed  from  the  surface  of 
the  filling,  and  the  surface  not  burnished  down  solid 
and  smooth.  Mercury  oxydates  with  considerable 
rapidity  when  exposed  to  air  and  moisture,  and  with 
increased  energy  under  the  influence  of  heat,  espe- 
cially when  some  acid  is  present.  This  facility  of 
oxydation  is  still  increased  when  other  metals  are 
combined  with  mercury.  Oxydation  of  such  fillings 
will  in  some  cases  be  confined  to  the  surface,  wher- 
ever there  is  contact  of  moisture ;  in  others,  it  will 
pervade  the  whole  mass,  rendering  it  black  and 
spongy  throughout. 

Amalgam  fillings,  in  a  short  time  after  their  inser- 
tion, undergo  a  hardening  process,  occasioned  by 
crystallization  of  the  mass,  as  well  as  by  evaporation 
of  the  mercury.  The  consequence  is,  either  that  the 
mass  becomes  porous,  or  that  it  contracts  ;  the  foriner, 
doubtless,  in  cases  where  the  oxydation  extends 
through,  and  the  latter  where  it  is  confined  to  the 


MATERIALS    FOR    FILLING.  95 

surface.  When  a  plug  is  in  either  of  these  condi- 
tions, the  preservation  of  a  tooth  is  very  uncertain. 
On  removing  an  ordinary  amalgam  plug  that  has 
been  worn  for  some  time,  its  entire  surface  will 
generally  be  found  oxydized  ;  and  a  tooth  filled  with 
this  material  generally  becomes  blackened,  and  its 
appearance  ruined. 

To  such  objections  against  this  material,  another  is 
to  be  added  in  cases  in  which  there  are  fillings  or 
plate  of  j)latinum  or  gold  :  galvanic  action  will  be 
established,  in  a  degree  proportionate  to  the  proxi- 
mity and  extent  of  surface  of  the  metals  and  the 
condition  of  the  secretions.  This  may  occasion  much 
mischief.  Some  constitutions  are  very  susceptible  of 
the  influence  of  mercury ;  and  a  gradual  decomposi- 
tion of  several  amalgam  fillings  in  the  mouth  may 
seriously  impair  the  general  health.  Therefore,  before 
this  material  is  ever  employed,  the  health,  tempera- 
ment and  habits  of  the  patient  should  be  carefully 
noted ;  for  these  and  other  circumstances  may  often 
indicate  its  inadmissibility. 

So  great  and  so  numerous  are  the  objections  to 
this  material,  that  it  is  wholly  discarded  by  some  in 
the  profession,  and  but  sparingly  used  by  a  great 
many  others.  Its  adaptability  is  the  main  property 
on  which  are  based  the  arguments  in  its  favor.  It  is 
easily  applied,  and  becomes  very  hard  upon  crystal- 


96  GENERAL   REMARKS    OX    FILLING. 

lizing.  It  is  affirmed^  also,  that  teeth  which  cannot 
be  saved  with  anything  else  may  be  filled  with  this, 
and  made  valuable.  This,  however,  is  not  true  since 
the  employment  of  the  cohesive  property  of  gold, 
which  quality  renders  this  metal  equal  in  adaptability 
to  amalgam. 

Oxy-chloridc  of  Zinc. — This  preparation  is  of  a 
semi-metallic  character ;  it  consists  of  oxyd  of  zinc 
and  chloride  of  zinc  in  combination,  and  hence  is 
commonly  denominated  oxy-cliloride  of  zinc. 

Os  Artificial  is  a  conventional  name  of  rather 
doubtful  propriety,  ^his  preparation  has  been  for 
quite  a  number  of  years  in  very  general  use; 
and  when  well  prepared,  and  properly  manipulated, 
serves  a  very  a  aluable  purpose.  In  some  cases  it 
resists  the  secretions  .of  the  mouth  quite  effectually. 
For  proximal  fillings  it  resists  the  wear  of  mastica- 
tion well,  but  for  crown  fillings  it  is  not  sufficiently 
resistant.  It  is  one  of  the  best  materials  for  tempo- 
rary fillings.  A  little  experience  renders  its  use  easy. 
It  effectually  excludes  all  foreign  substances,  is  a 
good  non-conductor,  and  is  only  displaced  by  wear 
and  the  sohcnt  power  of  the  saliva  in  some  vitiated 
conditions.  Guilloi's  Cement,  and  Cement  Plomb  are 
preparations  in  all  practical  aspects  similar  to  oxy- 
chloride  of  zinc.  Some  variation  in  the  method  of 
manipulating  them  is  required.     There  is  found  some 


MATERIALS    FOR    FILLING.  97 

difference  of  susceptibility  in  these  different  prepara- 
tions to  the  vitiated  secretions  of  the  mouth.  It 
is  a  good  protection  to  sensitive  dentine,  and  in 
many  cases  for  exposed  pulp,  under  gold  filling.  It 
more  nearly  resembles  the  natural  teeth  in  color  than 
any  other  material  that  has  been  used  for  filling. 

Non-metallic  Materials. — Of  the  non-metallic  mate- 
rials employed  for  filling  teeth,  there  are  not  many 
worthy  of  any  particular  consideration.  Indeed, 
gutta-percha  and  its  preparations  constitute  the  chief 
of  these  substances  now  used  for  this  purpose,  though 
some  others  have  been  employed.  Gutta-percha  is 
useful  for  temporary  fillings,  and,  under  ordinary  cir- 
cumstances, is  sufficiently  durable.  It  is  valuable 
for  filling  those  teeth  which  it  may  be  desirable  to 
retain  only  a  short  time,  or  those  in  which  it  may  be 
necessary  temporarily  to  protect  a  sensitive  part 
against  the  influence  of  irritating  agents,  in  order  to 
restore  it  to  health.  Gutta-percha  is  not  readily 
decomposed  by  the  fluids  of  the  mouth,  when  they 
are  in  a  healthy  condition.  In  some  instances  we 
have  known  it  worn  in  the  mouth  for  years  with  but 
little  change.  But  in  cavities  on  the  grinding  sur- 
faces of  the  molars  and  bicuspids,  it  will  not  with- 
stand the  wear  of  mastication  a  great  while,  though 
long  enough  in  most  cases  to  subserve  the  purposes 
of  temporary    fillings.     It   possesses   great   adapta- 


98  GENERAL   REMARKS    ON    FILLING. 

bility.  By  simply  being  warmed  over  a  spirit-lamp 
or  in  boiling  water,  it  becomes  plastic,  and  is  with 
great  facility  introduced  and  conformed  to  the  cavity. 
It  may  be  applied  also  in  solution,  being  dissolved  in 
chloroform  till  it  approaches  a  pasty  consistence,  then 
absorbed  in  a  pledget  of  cotton,  and  introduced  into 
the  cavity,  where  the  chloroform  evaporating,  leaves 
the  gutta-percha  as  a  filling.  The  only  objection  to 
this  method  J  is  the  contraction  consequent  on  the 
evaporation  of-  the  chloroform.  Another  property 
that  renders  this  substance  highly  valuable,  is  its 
non-conduction  of  heat,  it  being  in  this  respect  as 
nearly  perfect  as  any  other  material  employed. 

A  preparation  of  gutta-percha  with  mineral  sub- 
stances, known  as  HilVs  stoppi7ig,  has  for  some  years 
been  extensively  used  for  temporary  fillings ;  indeed, 
it  has  superseded  simple  gutta-percha  almost  entirely. 
The  aim  of  this  preparation  was  to  obviate  two  or 
three  objections  to  pure  gutta-percha;  as,  its  contrac- 
tibility  in  the  cavity,  its  softness  and  its  color.  The 
composition  of  HilVs  stopping  is  as  follows  :  With 
pure  gutta-percha  in  a  plastic  state  are  mixed  quick- 
lime two  parts,  and  quartz  and  feldspar  one  part 
each,  which  latter  are  reduced  to  an  impalpable 
powder,  and  kneaded  into  the  mass  as  long  as  it  will 
receive  them  without  becoming  brittle.  Such  is  the 
formula  given   by  the  inventor  of  this  preparation ; 


MATERIALS    FOR    FILLING.  9& 

though  it  is  presumed  that  one  of  these  materials 
alone,  namely,  pulverized  quartz,  would  be  found 
entirely  sufficient,  since  it  is  capable,  by  itself,  of 
<iuite  as  much  as  is  attained  by  all  together.  The 
addition  of  gold  or  platinum  fillings  has  been  recom- 
mended ;  but  no  advantage  is  thus  gained.  It  was 
at  first  claimed  for  this  material  that  it  would  serve 
for  permanent  fillings  ;  but  it  was  soon  demonstrated 
to  be  insufficient.  It  was  supposed,  also,  that  it 
might  be  employed  for  partial  fillings  in  large  cavities, 
which  could  be  completed  with  gold ;  but  for  this, 
too,  it  was  found  impracticable,  since  it  did  not  make 
a  sufficiently  firm  foundation. 

This  preparation  is  applied  in  the  same  manner  as 
simple  gutta-percha,  being  warmed  on  a  porcelain  or 
metal  slab  over  a  spirit-lamp  till  sufficiently  soft,  and 
then  packed  into  the  cavity.  It  cannot  be  employed 
in  the  form  of  solution,  nor  should  it  be  softened  in 
boiling  water.  It  may  be  conveniently  prepared  by 
dissolving  the  gutta-percha  in  chloroform  to  almost 
a  pasty  consistence,  then  adding  the  mineral  sub- 
stances, and  putting  it  into  a  vessel  suitable  for  the 
evaporation  of  the  chloroform.  It  should  be  made  so 
thick  that  the  silex  would  not  fall  to  the  bottom. 
When  HiWs  stopping  or  gutta-percha  is  used,  as  soon 
as  the  cavity  is  filled,  an  instrument  with  the  end 
nearly  as  large  as  the  orifice  of  the  cavity,  should  be 


100  GENERAL    REMARKS    ON    FILLING. 

placed  upon  the  filling,  and  retained  there  with  con- 
siderable pressure  till  the  mass  is  cool.  After  cutting 
and  dressing  the  surface  of  the  filling  as  thoroughly  as 
can  be  with  instruments,  then  by  passing  over  the 
surface  a  short  camel's-hair  brush,  with  chloroform,  a 
very  smooth  surface  and  perfect  finish  will  be  made. 
In  some  respects,  there  is  perhaps  nothing  better 
for  temporary  fillings  than  this  preparation  of  gutta- 
percha. 


CHAPTER  IV. 

INSTRUMENTS    FOR    FILLING. 

In  describing  the  instruments  for  filling  teeth,  it 
will  be  convenient  to  take  them  somewhat  in  the 
order  in  which  they  are  employed  in  ordinary  prac- 
tice ;  first  referring  to  those  which  are  used  for  cut- 
ting away  portions  of  the  teeth,  for  the  purpose  of 
separating  them,  and  for  dressing  off  the  borders  of 
cavities ;  then  to  those  for  removing  decay  and  form- 
ing the  cavities ;  and  finally  to  those  for  introducing, 
consolidating,  and  finishing  fillings.  The  first,  then, 
that  claim  our  attention,  are  the 

HEAVY    CUTTING-INSTRUMENTS. 

These  are  of  the  thick  chisel-shape.  They  should 
be  of  good  steel,  well  wrought,  and  thoroughly  tem- 
pered. Every  step  in  the  process  of  their  manufac- 
ture should  be  most  perfectly  executed,  so  as  to 
insure  an  edge  that  will  cut  not  only  dentine,  but 
also  enamel,  which  is  the  hardest  animal  substance. 
Various  sizes  of  the  straight  chisel-form  are  required. 

In  all  cases  they  should  be  as  thick  as  possible,  with- 
out being  thus  impaired  in  their  efficiency ;  so  firm 


102 


INSTRUMENTS    FOR    FILLING. 


that  there  may  be  no  springing  or  tremulous  motion 
under  the  pressure  they  are  required  to  sustain.  For 
separating  front  teeth,  however,  they  must  be  thin 
enough  to  pass  readily  into  the  intended  space,  and 


FiL^ 


about  one-fourth  of  an  inch  wide  at  the  edge.  But 
for  separating  bicuspids  and  molars,  the  instruments 
should  be  thicker  and  broader ;  as  thick,  indeed,  as 

Fig.  4. 


the  required  space  will  admit.     In  some  cases  they 
should  have  the  edge  oblique,  as  in  Fig.  5. 

It  is  seldom  that  these  instruments  need  any  curve. 


The  straight  form  is  the  best,  unless,  as  rarely  hap- 
pens, the  point  to  be  operated  upon  cannot  be  reached 
efficiently  with  it ;  as,  for  instance,  in  a  small  mouth, 
a  slight  anterior  curve  w411  be  required  in  the  shaft 
of  the  instrument,  to  facilitate  its  approach  to  the 
front  proximal  surface  of  a  second  or  a  third  molar. 


HEAVY    CUTTING-INSTRUMENTS. 


103 


Fig.   6,    a   heavy   instrument,    with    a   sharp    point 
and  a  lateral  curve,  is  often  efficient  in  opening  up 


Fiff.  6. 


cavities  and  cutting  down  strong  projections  of 
enamel.  Fig.  7  we  consider  as  a  very  valuable 
form.     Every  operator  should  have  at  hand  a  suffi- 


Fig.  7. 


cient  variety  to  meet  every  demand — from  three  to 
five  sizes  of  each  form. 

These  instruments  are  now  made  with  steel  han- 
dles; much  smaller  than  those  represented  above,  and 
are  used  with  the  mallet. 

The  following  (Fig.  8)  will  give  an  idea  of  the 
variety  of  sizes  that  are  desirable  : 

Fig.  8.     • 


\  / 


r  \ 


\  / 


\f  \ 


104 


INSTRUMENTS  FOR    FILLING. 


DRILLS. 

Bur  Drills. — Of  this  indispensable  class  of  instru- 
ments there  are  Aarious  forms.  They  should  be  manu- 
factured of  the  best  steel,  and  wrought  with'  the 
greatest  care.  After  having  been  forged  as  near  the 
proper  size  as  possible,  the  bulb  is  shaped  by  dressing 
with  a  fine  file,  or,  which  is  better,  by  turning  in  a 
lathe,  those  made  by  the  latter  method  being  supe- 
rior, and  cutting  much  more  smoothly ;  they  do  not 
catch  and  jar  as  do  those  of  less  regular  form.  After 
the  bulb  is  formed,  it  is  cut  with  a  sharp-edged  file. 

Fig.  9. 


Of  these  drills.  Fig.  9  represents  a  bur  of  a  spher- 
ical form.     Fig.  10  is  cone-shaped,  which  may  have 

Fig.  10. 


various  degrees  of  bevel,  terminating  in  a  sharp  point. 
Fig.  11  is  of  a  cylindrical  form,  cut  upon  the  sides 


Fiff.  11. 


and  end.     Fig.  12  is  in  the  form  of  a  wheel,  cut  upon 


DRILLS.  105 

tKe  edge  only,  or  upon  both  the  edge  and  the  end. 
The  cutting  upon  ail  of  these  should  be  very  regular 
and  uniform.  This  should  be  made  by  machinery, 
though  it  is  usually  done  by  hand.     Of  these  instru- 

Fis.  12. 


ments,  there  should  be  a  variety  in  size,  the  smallest 
considerably  less  than  the  smallest  cavity  the  dentist 
ever  attempts  to  fill — that  is  about  one  thirty-second 
of  an  inch  in  diameter,  and  the  largest  about  one- 
fifth  of  an  inch.  Inclusive  of  these  extremes,  there 
should  be  about  ten  sizes  of  each  particular  form. 
These  instruments  are  used  for  opening  cavities. 
With  them  a  more  regular  and  perfect  orifice  is  made 
in  small  and  medium-sized  cavities  than  by  any  other 
method.  They  are  also  used  to  some  extent  for 
forming  the  cavities,  and  even  sometimes,  in  large 
cavities,  for  making  retaining-points  for  a  filling. 

Some  years  ago,  Dr.  Scranton  devised  a  rather 
peculiar  kind  of  drill,  and  efficient  withal.  Its  form 
is  spherical,  and  in  its  manufacture  the  bulb  is  made 
as  for  the  ordinary  bur  drill ;  but  instead  of  having 
cut  upon  it  numerous  serrations,  thus  forming  a 
series  of  sharp  edges,  a  concave  cut  is  made  upon 
two  opposite  sides  with  a  small  round  file.  The 
instrument  then  presents  two  concave  and  two  convex 


106 


INSTRUMENTS    FOR    FILLING. 


sides,  with  four  sharp  longitudinal  edges ;  these  i«ay 
be  so  inclined  as  to  cut  only  when  rotated  in  one 
direction,  or  to  operate  alike  well  when  rotated 
either  to  the  right  or  the  left. 

This  instrument  has  two  or  three  advantages  over 
the  ordinary  bur ;  it  can  be  kept  sharp  with  the  oil 
stone  till  it  is  almost  entirely  used  up,  and  will  con- 
sequently last  much  longer;  and  it  w^ill  cut  much 
more  rapidly  than  the  serrated  bur.  It  is  a  very 
valuable  instrument  for  operating  upon  firm,  strong 
teeth.     It  is  represented  in  Fig.  13. 


Fiii.  13. 


z 


Common  Drills. — Of  other   drills,  Fig.  14  repre- 
sents one  with   a  square  point,   beveled  from  both 


14. 


sides,  measuring  from  a  half  to  a  whole  line  in 
width,  and  attached  to  a  small  round  shaft.  The 
edges  of  the  drills  should  be  very  hard,  so  that  they 
may  cut  with  the  greatest  celerity.  Of  this  kind 
there  should  be  about  ten  sizes,  ranging  in  width 


from  No.  12  to  No.   25  of   Stubb's  gauge. 


These 


DRILLS. 


107 


are    used    mainly   for   forming    retaining-points    in 
cavities. 

Fig.   15  is  the   spear-shaped    drill,   the   edges   of 
which  are  formed  by  dressing  from   both  sides ;  or, 

Fig.  15. 


it  may  be,  from  only  one,  in  which  case  it  will  cut 
only  when  rotating  one  way.  This  shape  is  employed 
principally  for  drilling  out  roots  for  filling,  or  receiv- 
ing pivot  teeth. 

The  burs  and  drills  may  be  made  of  pieces  of  wire 
one  inch  and  a  half  long,  and  fitted  to  a  socket- 
handle  that  will  accommodate  a  large  number ;  or  of 
a  continuous  piece  of  large  wire.  The  latter  is  the 
preferable  method,  since  much  time  is  consumed  in 
changing  them  in  sockets.  The  handles  should  be 
made  with  six  or  eight  sides,  and  cut  on  each  alter- 
nate side.  In  the  use  of  these  instruments,  the 
drill-ring  is  almost  indispensable.  This  is  a  ring 
used  on  the  middle  or  the  index  finger,  with  a 
socket  attached,  in  which  rests  the  end  of  the  handle 
of  the  instrument.  (Fig.  16.)  The  drill  is  rotated 
commonly  with  the  thumb  and  fingers. 


108  INSTRUMENTS   FOR   FILLING. 

Fig.  16. 


Drill-stocJcs  of  various  forms  have  been  invented, 
with  the  view  of  increasing  the  motion  of  the  drill, 
of  augmenting  its  power,  and  especially  of  bringing 
it  to  bear  upon  points  inaccessible  to  the  straight 
instrument. 

The  use  of  the  burs  and  drills  by  the  hand,  and 
by  means  of  the  various  drill-stocks,  has  been  almost 
wholly  superseded  by  the  introduction  and  use  of 
the  dental  engine. 

This  appliance,  in  a  far  less  perfect  form  than  now, 
was  introduced  to  the  dental  profession  about  the 
year  1870. 

Mr.  Green,  of  Michigan,  first  introduced  the  pneu- 
matic engine;  succeeding  this,  was  that  denominated 
The  "Morrison  Engine."  Within  a  short  time  after 
this,  the  suspension  engine  was  devised  and  con- 
structed by  Dr.  W.  S.  EUiott. 


109 


110  INSTRUMENTS    FOR    FILLING. 

This  engine  possesses  some  excellent  qualities. 
Its  steadiness  of  motion,  freedom  from  tremor  or 
backlash,  and  the  facility  of  use,  are  qualities  that 
make  it  very  valuable  in  these  respects.  When  the 
large  dressing  burs  or  polishing  cones  are  being  used, 
it  is  superior  to  any  other. 

The  illustration  on  page  109  (Fig.  17)  gives  a  cor- 
rect idea  of  the  machine. 

Various  other  modifications  of  dental  engines  have 
from  time  to  time  been  presented,  a  description  of 
which  is  unnecessary  here.  That  improved  by,  and 
bearing  the  name  of,  S.  S.  White,  is  at  present  very 
popular;  it  has  now  the  most  prominent  position 
before  the  profession ;  other  modifications,  however, 
are  highly  esteemed  by- many.  It  is  well  represented 
by  the  illustration  on  page  111  (Fig.  18). 

This  engine  certainly  posesses  many  desirable 
qualities.  The  facility  of  movement  and  adapta- 
tion afforded  by  the  flexible  cable,  and  the  hand- 
piece, seem  to  be  about  all  that  can  be  desired. 
The  mode  of  attachment  to  and  retention  of  the 
drills  and  other  accessories  by  the  hand-piece, 
leaves  little  or  nothing  more  to  be  desired  in  that 
direction. 

Attachments  are  made  to  the  hand-piece  by  which 
drills  are  operated  at  a  right  angle  with  the  shaft, 
and  also  at  an  acute  angle,  or  with  a  backward  incli- 


DRILLS. 


Ill 


Fiff.  18. 


112 


INSTRUMENTS    FOR    FILLING. 


nation  to  almost  forty-five  degrees.    They  are  shown 
in  Fig.  19. 


Fig.  19. 


Some  description  and  illustration  of  the  instru- 
ments and  appliances  used  with  the  engine  might 
appropriately  be  given  here ;  but  so  numerous  have 
they  become  that  it  is  impracticable  to  give  more 
than  a  representation  of  each  class. 

Fig.  20. 


Fig.  20  presents  illustrations  of  the  spherical  and 
wheel  burs,  three  sizes.  Of  each  class  of  burs  there 
should  be  eight  or  ten  sizes ;  it  would  also  be  well 
to  have  two  or  three  grades,  as  respects  fineness  of 
cut :  the  coarser  will  serve  for  rapid  work,  and  the 
finer  for  the  smooth  and  more  perfect  work. 


DRILLS. 


113 


This  variation  may  with  propriety  pertain  to  all 
forms  of  burs  used  upon  the  teeth,  and  those  used 
for  dressing  fillings  as  well. 

Fig.  21  shows  the  cone  and  the  inverted  cone- 
shaped  burs ;  about  the  same  variety  in  number  and 
size  will  be  required  as  of  the  spherical. 

Fig.  21. 


In  Fig.  22  are  presented  the  fissure  burs,  square 
and  pointed. 


Fis.  22. 


In   Fig.  23  are  shown  the  bud-shaped  and   oval 
burs. 

Fig.  23. 


114 


INSTRUMENTS    FOR    FILLING. 


In  the  following  illustration  are  shown  the 
flexible  burs  and  drills  for  operations  in  canals  of 
roots. 


lis.  24. 


Fig.  25  shows  the  spear,  the  square  edge,  and  the 
spade-shaped  drills,  all  flat,  and  the  twisted  drill. 


Fig.  25. 


The  burs  and  drills  here  presented  embrace  all 
the  principles  that  have  been  employed  in  the  ordi- 
nary operations  upon  the  natural  teeth. 

Of  the  plug-dressing  burs  a  large  variety  is  made ; 
nearly  the  same  general  forms  have  been  adopted 
as  in  those  for  operating  in  cavities  of  decay. 


DRILLS. 


115 


The  following  illustration  gives  the  most  common 


forms 


In  the  followino;   is    shown   a   set   of  burnishers 


for  finishing  fillings. 


YUs.  2- 


The  following  illustrates  a  set  of  corundum  points, 


cones  and  disks  for  finishing  fillings. 


Fill.  lib. 


About  the  same  forms  and  sizes  of  points  for 
finishing  are  made  of  Arkansas,  Scotch,  and  ITin- 
dostan  stones.     These  are  all  valuable,  and  should 


116 


INSTRUMENTS    FOR   FILLENG. 


always  be  at  hand,  and  a  sufficient  variety  of  sizes 
to  meet  all  cases.     They  are  shown  by  Fig.  29. 


Fig.  29. 


EXCAVATORS. 

Of  the  small  cutting-instruments  for  opening  and 
forming  cavities,  and  removing  decay  from  them, 
there  is  a  great  variety,  though  a  few  general  forms 
comprise  the  whole.  Until  within  comparatively  a 
short  time,  there  has  been  no  very  systematic  arrange- 
ment of  these  instruments,  such  as  the  convenience 
both  of  the  profession  and  the  manufacturers  of 
dental  instruments  would  seem  to  dictate.  In  a 
classification  that  we  have  adopted  and  found  very 
convenient,  they  are  arranged  by  numbers,  the  most 
simple  being  placed  under  the  first,  and  under  each 
successive  number  a  more  complicated  form.  All 
the  varieties  are  embraced  in  twelve  numbers, 
which  are  represented  in  Fig.  30.  These  varieties 
are  discriminated  by  the  forms  of  the  points,  and 
their  position  on  the  shaft  to  which  they  are  attached, 
and  not  by  any  curve  which  the  shaft  may  have  at 
any  distance  from  the  point. 


EXCAVATORS. 


117 


No.  1  has  simply  a  flat  point  slightly  curved, 
with  a  round  edge  transverse  to  the  shaft.  Four 
sizes  will  be  sufficient  for  ordinary  purposes. 

Fig.  30. 


No.  2  has  a  flat  point  with  a  short  curve,  bring- 
ing the  point  to  a  right  angle  with  the  shaft;  the 
edge  is  transverse.  This  differs  from  No.  1  in 
having  the  curve  more  short  and  abrupt,  and  the 
edge  more  nearly  square.  Of  these  there  should 
be  five  sizes,  with  some  variety  of  form. 


118  INSTRUMENTS    FOR    FILLING. 

Ko.  3  has  a  flat  point  with  a  square  transverse  edge, 
which  rises  at  a  right  angle  from  the  shaft ;  the  blade 
being  from  one  to  two  lines  in  length.     Five  sizes. 

No.  4  has  a  flat  point,  curved  so  as  to  be  at  a 
right  angle  with  the  shaft;  the  blade,  from  the 
centre  of  the  curve  to  the  edge,  being  from  one  and  a 
half  to  three  lines,  and  the  edge  straight.    Four  sizes. 

In  each  of  the  foregoing  the  edges  should  expand 
slightly  in  width. 

No.  5  has  a  flat  point  with  a  square  edge,  which 
is  parallel  with  the  shaft,  and  rises  at  a  right  angle 
from  it.  The  blade  is  from  one-half  to  two  and  a  half 
lines  in  length,  and  from  one-half  to  one  line  in  w^idth, 
with  no  expansion  at  the  edge.  Six  sizes,  with 
some  variety  of  form. 

Nos.  6  and  7  are  right  and  left  excavators,  with 
flat  points  and  double  curves ;  the  first  curve  being 
at  an  angle  of  about  twenty  degrees,  and  the  other 
lateral,  right  and  left,  reaching  from  the  beginning 
of  the  first  curve  to  the  point.  The  length  of  blade 
is  from  one  to  three  lines.     Four  sizes. 

No.  8  has  a  crescent-shaped  point,  the  blade 
rising  by  a  small  attachment  from  the  shaft,  and 
making  a  right  angle  with  it.  The  edge  is  a  regular 
curve,  describing  about  two-fifths  of  a  circle,  and 
is  parallel  with  the  handle.  The  point  should  be 
perfectly  formed.     Six  sizes. 


EXCAVATORS.  119 

No.  9.  The  form  of  the  point  is  the  same  as  in 
No.  8,  the  difference  being  in  the  position  of  the 
blade,  the  edge  of  which  is  transverse  to  the  shaft, 
and  rises  from  it  at  an  angle  of  one  hundred  and 
thirty  degrees.     Six  sizes. 

In  No.  10  the  point  has  the  same  shape  as  in 
Nos.  8  and  9.  The  cutting  edge  is  transverse  to 
the  shaft,  and  rises  by  a  small  neck  at  a  right  angle 
from  it.     Six  sizes. 

Such  are  the  most  important  forms  of  excavators, 
though  modifications  will  be  required  for  particular 
cases.  While  Nos.  8,  9,  and  10  are  not  in  exten- 
sive use,  a  few  operators  have  used  them  for  some 
years,  and  prize  them  very  highly.  In  many  diffi- 
cult cases  they  are  far  more  applicable  than  any 
other  instrument  we  have.  For  instance,  in  the 
formation  of  the  cervical  wall  of  a  proximal  cavity 
in  any  of  the  teeth,  but  particularly  in  the  superior 
bicuspids  and  molars,  there  is  no  other  instrument 
so  applicable  and  efficient  as  No.  9 ;  with  it,  that 
part  of  the  cavity,  so  frequently  neglected,  is  just 
as  easily  formed  as  any  other. 

Cases  will  occasionally  be  presented  in  which 
some  curvature  of  the  shaft  of  the  instrument  will 
be  requisite.  But  no  more  curve  should  be  given 
to  any  instrument  than  may  be  absolutely  neces- 
sary, for  it  is  impossible  to   manipulate  with  the 


120  INSTRUMENTS   FOR   FILLING. 

same  precision  and  delicacy  with  curved  as  with 
straight  instruments.  The  degree  of  curve  neces- 
sary in  any  given  case  will  be  determined  by  the 
position  of  the  decay  on  the  tooth,  and  the  location 
of  the  latter  in  the  mouth. 

The  diamond  point,  as  it  is  familiarly  called,  is 
a  modification  of  No.  3,  varying  from  it  in  that  it 
has  a  sharp  point  instead  of  a  square  edge,  and  is 
three-sided  from  shaft  to  point,  each  angle  being 
a  cutting  edge.  This  instrument  is  especially  valu- 
able for  forming  grooves  or  furrows  within  cavities, 
and  for  dressing  the  borders. 

After  being  much  reduced  by  use,  it  may  still  be 
kept  in  form,  and  sharp,  and  used  as  a  drill  for 
making  under-cuttings,  for  which  it  is  very  efficient. 
No.  11  represents  this  instrument. 

A  modification  of  No.  9,  commonly  known  as 
the  scoop  or  spoon-shaped  instrument,  is  extensively 
used.  The  sharp  corners  of  No.  9  are  removed 
in  this  instrument.     It  is  shown  in  No.  12. 

Since  the  issue  of  the  second  edition  of  this  work, 
efforts  have  been  made  by  several  members  of  the 
profession  to  arrange  and  systematize  excavators 
into  sets,  that  should  embrace  every  desirable  form 
and  size.  No  one  has  as  yet  succeeded  in  pro- 
ducing that  which  meets  the  views  of  all  operators. 

There  is,  perhaps,  now  more  diversity  of  opinion 


EXCAVATORS. 


121 


and  practice  in  reference  to  the  use  of  hand  ex- 
cavators, in  the  prej^aration  of  teeth  for  filling,  than 
ever  before,  from  the  fact  that  a  great  diversity  of 
practice  exists  in  reference  to  the  use  of  the  dental 
engine  and  its  accessories  for  this  purpose;  some 
using  these  almost  exclusively  in  the  preparation 
of  cavities;  others  for  this  purpose  making  far  less 
use  of  the  engine,  and  more  use  of  the  hand  ex- 
cavators, claiming  that  with  the  latter  much  more 
precise  and  definite  execution  can  be  attained. 

Fig.  31  presents  an  arrangement  of  excavators  by 


Fig.  31. 

fii      a 


0     !     I 


/f 


Dr.  I.  J.  Wetherbee,  very  good  indeed  so  far  as  they 
extend,  and  perhaps  in  the  majority  of  cases  they 
would  quite  suffice. 

Of  the  Manufacture  of  Excavators. — For  making 
these  instruments,  the  best  cast-steel  wire.  No.  8, 
should   be  selected.     This   should    be  forged   down 


122  INSTRUMENTS   FOR   FILLING. 

SO  as  to  leave  the  end  large  enough  to  form  the 
intended  point.  Nos.  1  to  6  inclusive,  Fig.  30, 
may  be  formed  by  forging,  and  afterward  dressing 
up  with  the  file.  Nos.  8  to  12  inclusive  should 
be  formed  by  the  files  out  of  a  bulb  left  from  the 
forge ;  for  this  purpose  different  forms  and  sizes  of 
files  will  be  required,  in  order  definitely  to  shape  all 
the  angles  and  points.  In  heating  steel,  either  for 
forging  or  tempering,  a  full  red  heat  should  in  no 
case  be  exceeded,  since  a  higher  degree  than  this 
spoils  it.  After  the  points  are  formed,  and  made 
smooth  with  an  emery  stick  or  wheel,  they  are  to 
be  tempered ;  this  is  a  delicate  process,  requiring 
much  experience  and  care.  The  point  should  be 
warmed  in  a  spirit-lamp,  and  then  covered  with 
soap,  to  prevent  oxydation  and  scaling.  The  in- 
strument is  then  brought  up  to  a  full  red  heat 
with  a  spirit-lamp,  blow-pipe,  and  charcoal,  and 
suddenly  plunged  into  a  cake  of  soap  or  into  cold 
Avater,  when  it  will  present  a  silvery  whiteness ; 
the  steel  in  this  condition  is  extremely  hard  and 
friable.  It  should  then  be  polished  off  with  an 
emery  stick  or  oil-stone,  and  drawn  down  to  the 
proper  temper.  This  tempering  is  accomplished 
by  placing  the  edge  of  the  instrument  on  a  piece 
of  cold  polished  steel  or  iron,  and  its  shaft  placed 
near   or   in   the    flame    of  a  small  spirit-lamp,  and 


EXCAVATORS.  123 

retaining  it  there  till  it  changes  to  a  deep  blue 
color,  graduated  doAvn  to  the  point  in  a  deep  straw 
or  copper  hue.  The  purpose  in  holding  the  point 
of  the  instrument  on  a  piece  of  cold  polished  iron 
or  steel  is.  that  the  heat  there  may  be  subject 
to  complete  control.  The  precise  shade  will  be 
governed  by  the  purpose  for  which  the  instru- 
ment is  to  be  used ;  if  for  a  drill,  the  edge  or 
point  should  be  of  a  light  straw  color;  indeed, 
some  operators  prefer  to  have  them  scarcely 
changed  at  the  cutting  edge,  while  excavators 
and  chisels  should  be  brought  to  a  deep  straw  or 
copper  color ;  this  will  be  modified,  however,  by 
the  manner  of  working  the  steel,  and  its  quality. 
Skillfully  hammering  steel  at  a  low  heat — below 
a  red — adds  much  to  its  quality  for  a  fine  cutting 
instrument,  and  gives  an  improved  texture.  In- 
deed, some  assert  that  those  instruments  that 
can  be  forged  to  nearly  their  proper  shape,  can  be 
as  well,  if  not  better,  tempered  by  the  hammer  as  by 
anv  other  means. 

The  instrument  is  then  to  be  polished  by  the 
emery  wheel  and  dressed  up  with  the  oil-stone. 
Of  the  various  methods  of  tempering,  the  fore- 
going is  equal  in  efficiency,  and  in  convenience 
superior,  to  any  other. 


124 


INSTRUMENTS    FOR    FILLING. 


FILLING    INSTRUMENTS. 

For  introducing  and  consolidating  fillings,  a 
great  variety  of  instruments  is  in  use.  In  every 
form  in  which  gold  is  employed  for  filling  teeth, 
the  pliers  are  required  for  taking  up  the  pieces 
and  placing  them  in  the  proper  position  in  the 
cavity;  in  cylinder  or  block-filling  they  are  in- 
dispensable. These  instruments  are  made  of  dif- 
ferent forms  and  sizes — of  such  forms  as  to  facili- 
tate access  to  cavities  inconveniently  located ;  of 
different  sizes,  to  accommodate  cavities  of  various 
capacities.  For  a  large  majority  of  cases,  they 
require  a  slight  curve,  about  half  an  inch  from  the 

Fig.  32. 


point;  for  some   cases,  however,  the   curve  should 
be  a  right-angle.     (Fig.  32.) 

The    points    of    the   pliers   when   closed    should 
present   such   a  form   as   to   be  used,  to  some  ex- 


FILLING    INSTRUMENTS. 


125 


tent  at  least,  for  consolidating  the  gold.  This 
instrument  should  be  about  five  inches  long. 

The  forms  of  condensing  instruments  may  be 
multiplied  to  an  almost  indefinite  extent.  They 
are  all,  however,  but  modifications  of  two  or  three 
general  principles.  The  particular  form  of  the 
plugging  point  will  be  determined  by  the  form 
in  which  the  gold  is  used.  With  non-cohesive 
gold,  small  square,  or  round,  sharp  points  of 
various  curves  are  required.  These  points  are 
easily  kept  in  proper  condition,  and  in  some  in- 
stances are  used  for  years  without  any  change 
or  repair. 

A  favorite  method  of  filling  with  non-cohesive 
gold,  by  many  excellent  operators,  is  in  the  use 
of  cylinders  or  blocks ;  for  this  method,  instru- 
ments especially  adapted  have  been  devised,  which 
the  following  cut  represents. 

Fiir.  33. 


12G  INSTRUMENTS   FOR    FILLING. 

Fig.  34  is  square  from  the   curve   to   the  point, 

Fis;.  34. 


and   is  used   in  the   same  manner,  and  for  nearly 
the  same  purpose,  as  Fig,  33. 

For  introducing  and  condensing  key-blocks — those 
intended  to  bind  the  filling  in  place — Fig.  35  is 
the  proper  form. 


'ig.  or). 


Figs.  36  and  37  are  designed  for  condensing 
the  surface  of  crown  fillings,  in  the  superior  and 
inferior  molars  respectively. 


Fijr-  30. 


FILLING   INSTRUMENTS. 
Fie.  37. 


127 


The   instruments    represented    by    the  following 
are  for  condensing  the  surfaces  of  proximal  fillings. 


Fiff.  38. 


Fig.  39  represents  round  right  and  left  condens- 
ing points,  to  be  used  in  filling  proximal  cavities. 


Fig.  39. 


Figs.  40  and  41  are  flat,  right  and  left  condensing 
points,  for  same  cavities  as  Fig.  39. 

Fig.  40. 


128 


INSTRUMENTS    FOR    FILLING, 


The  following  cuts  represent  a  set  of  filling  in- 
struments devised  and  arranged  by  Dr.  W.  G. 
Redman. 


Fiff.  42. 


They  constitute  probably  the  most  complete  set 
made,  for  filling  with  blocks  or  cylinders  of  non- 
cohesive  gold.  They  are  made  with  ebony  or  ivory 
handles,  and  are  used  with  hand  force  only. 


FILLING    INSTRUMENTS. 


129 


With  cohesive  gokl  in  any  of  its  forms,  the 
points  all  require  to  be  serrated.  There  are  three 
or  four  varieties  of  these,  which  it  will  be  proper 
to  describe.  The  first  is  square,  and  slightly 
bent  about  half  an  inch  from  the  end,  which  is 
formed  into  four  or  six  definite  sharp  points  with 
the  edge  of  a  thin  file.  Of  this  variety  there 
should  be  about  five  sizes,  the  largest  entering 
No.  18  of  Stub's  gauge,  and  the  smallest  No.  38. 

Fiji.  43. 


The  former  should  have  six  points,  and  the  other 
two  sizes    four.     (Fig.  43.)     The  cuts    upon  these 


Fig.  44. 


are    made    directly   across    the    end.     In    another 
variety  the    end   is    rounded,    and   the    file    placed 


130 


INSTRUMENTS    FOR    FILLING. 


upon  it  at  an  acute  angle  with  the  side  of  the 
instrument,  and  the  cuts,  three  in  number,  are 
made    to    the    centre    of    the    point,   which    thus 


Fiff.  45. 


becomes  triangular,  or  three-pointed,  from  a  com- 
mon centre.  (Fig.  45.)  Four  or  five  sizes  of 
these  may  be  employed,  ranging  from  18  to  26, 
Stub's  gauge.  A  thin  double  point,  from  26  to  28, 
is  in  many  cases  very  valuable.  Instruments  with 
a  condensing  surface  on  the  side,  instead  of  the 
end,  will  frequentl}^  be  required  for  filling  lateral 
cavities ;  these  may  be  denominated  lateral  plug- 
gers.     (Fig.  46.)     This    condensing   surface  should 

Fis.  4G. 


also  be  serrated,  as  already  described.  An  in- 
strument square  at  the  point,  ranging  from  18 
to  22,  and  cut  upon  the  end  by  passing  it  along 
the  cuts  of  a  file  both  ways,  thus  making  a  large 


} 


FILLING    INSTRUMENTS. 


131 


number  of  small  serrations  at  right  angles  across 
the  point,  is  valuable  for  consolidating  the  sur- 
face of  a  plug.  (Fig.  47.)  Operating  superficially, 
on   the    principle  of  the  more   deeply  serrated    in- 


Fig.  47. 


struments,  it  yet  leaves  the  surface  free  from 
deep  pits  or  indentations,  and  still  so  impressed 
that  it  will  receive  and  retain  more  gold,  if  neces- 
sary, as  it  would  not  do  if  the  end  of  the  in- 
strument was  perfectly  smooth.  A  smooth-pointed 
instrument  or  burnisher  may  be  applied  after  all 
the  gold  has  been  added. 


Fig.  48. 


Fig.  48  is  an  instrument  with  file-cut  sides. 
It  is  valuable  for  dressing  down  proximate  fillings 
to  a  uniform  surface.  There  may  be  two,  one 
with    the    sides   parallel    with    the    shaft,   and    one 


132 


INSTRUMENTS    FOR    FILLING. 
Fig.  49. 


with  its  sides  transverse  to  the  shaft;  it  termi- 
nates in  a  sharp  edge. 

Ill  considering  this  subject  thus  for,  the  aim 
has  been  to  present  the  principles  that  should 
be  embraced  by  instruments  for  properly  filling 
the  various  classes  of  cavities  that  are  presented. 

Within  the  last  ten  years  great  changes  and 
improvements  have  been  made  in  this  class  of 
istruments,  especially  with  reference  to  classifying 
lid  systematizing  them. 

It  will  be  seen  by  the  accompanying  illustrations 
IJ  that  considerable  attention  has  been  given  in  this 
direction,  Fig.  49  presents  Dr.  W.  H.  Atkinson's 
'•  Omega"  pluggers. 

Those  wdio  have  become  familiar  with  these 
instruments  prize  them  very  highly. 

Dr.  F.  Abbott's  set  of  pluggers  are  also  regarded 
highly  by  many.     (Shown  in  Fig.  50.) 


Fig.  50  A. 


FILLING    INSTRUMENTS. 
Fiff.  50  B. 


133 


Fig.  51  A 


i 


This  cut  represents  Dr.  Lewis  Jack's  "  Matrix" 
pluggers.  They  are  designed  for  and  are  well 
adapted  to  operations  in  which  the  matrix  is  required. 

Fig.  51  B. 


Fig.  52  represents  Dr.  R.  W.  Varney's  set  of 
pluggers.  These  were  among  the  first  regularly 
arranged  sets  of  pluggers,  and  in  some  respects 
superior  to  any  that  preceded  them,  and  became 
very  popular. 

Fig.    53    represents    Dr.    C.    R.    Butler's    set   of 


134 


INSTRUMENTS   FOR   FILLING. 
Fig.  52  B. 


r  f 


fi 


pluggers,  different  in  some  respects  from  all  the 
others,  but  excellent  nevertheless,  and  better  adapted 
for  some  cases. 


Fig.  54  shows  in  many  important  respects  the  most 
perfect  set  {^^ inlugging  instruments  ever  made.  They 
are  the  result  of  long  and  patient  investigation ;  they 
will  be  at  once  recognized  as  the  work  of  Dr.  Cory- 
don  Palmer. 

The  following  cut  illustrates  them  as  well  as  the 
engraver's  art  can  do  it. 


FILLING   INSTRUMENTS. 


135 


i 


20        21         22       23       24-        25       26       27         28  29  30 


136 


INSTRUMENTS    FOR   FILLING. 


A  minute  description  of  each,  with  the  du'ect- 
ions  for  its  use,  is  given  in  section  B,  in  the 
Appendix. 

In  many  cases  a  valuable  instrument  for  con- 
solidating is  the  plugging  forceps,  the  general 
form  of  which,  except  the  beaks,  is  that  of  the 
ordinary  straight  extracting  forceps.  The  beaks 
are  formed  into  sockets  for  the  reception  of  the 
plugging  points,  one  of  which  is  of  the  common 
construction,  but  the    other   has    a  broad    flat  sur- 

Fig.  55. 


face,  to  rest  against,  the  tooth.  (Fig.  oo.)  This 
instrument  is  applicable  only  in  certain  cases,  prin- 
cipally in  filling  proximal  cavities.  Its  main  ad- 
vantage consists  in  its  capability  of  applying  a 
strong  pressure  upon  the  filling,  without  affecting 
the  socket.  Manipulation  with  it  is  less  rapid 
and  definite  than  with  the  ordinary  condensing  in- 
struments ;  and  with  it,  too,  there  is  much  danger 
of  fracturing  friable  teeth. 

There   has  been  within  the  last  few  years  very 
great  improvement  made  in   the  serrated   plugging 


FILLING   INSTRUMENTS. 


137 


instruments — those  employed  for  working  cohesive 
foil.  It  consists  in  delicacy  and  perfection  of  form, 
a  large  addition  to  the  variety,  and  a  good  system- 
atic arrangement. 

These  instruments  are  now  manufactured  and 
put  up  in  sets,  embracing  every  requisite  form,  num- 
bering from  forty  to  sixty ;  this  includes  surface 
condensers  and  burnishers. 

The  profession  is  largely  indebted  to  the  efforts 
of  Drs.  Palmer,  Atkinson  and  Abbott,  of  New 
York,  for  the  perfection  obtained  in  the  production 
of  these  instruments. 


THE   FILE. 

Of  this  valuable  and  indispensable  instrument 
there  are  a  variety  of  forms  used  by  the  dentist. 
The   thin  files    (Fig.  56)   are   chiefly  applicable    to 

Fig.  50. 


the  anterior;   the  thick,   heavy,  knife-shaped    (Fig. 


138 


INSTRUMENTS    FOR    FILLING. 


57),  to  the  posterior  teeth.  The  latter,  to  facilitate 
their  approach  to  the  points  operated  upon,  have 
various  curves,  some  single,  others  double ;  the 
double  being  preferable,  since  they  bring  the  handle 
of  the  instrument  on  a  line  with  its  cutting 
edge.     The    cuts     upon    this   instrument,    too,   are 

Fig.  57. 


^illMHi 


quite  various ;  in  size  ranging  from  very  coarse  to 
very  fine,  and  in  obliquity  from  a  line  almost  at 
right  angles  across  it  to  one  at  an  angle  of  forty- 
five  degrees.  These  cuts,  too,  are  either  single 
or  double,  the  double  being  those  made  across 
one  another.  The  single,  however,  are  preferable 
for  all  operations  on  the  teeth ;  and  the  more  ob- 
lique are  to  be  recommended,  since  they  cause 
less  of  that  jarring,  unpleasant  sensation  to  the 
patient. 

There  are  in  use  various  forms  of  file-carriers,  two 
of  which  are  represented  in  Figs.  58  and  59.     Fig. 


THE   FILE. 


Fiir.  58. 


139 


59,  denominated  "Redman's  file-carrier,"  is  an  excel- 

Fig.  59. 


lent  instrument,  one  principal  advantage  of  which 
consists  in  the  facility  with  which  it  may  be  changed 
from  the  one  side  to  the  other.  Files  are  made 
adapted  to  the  instrument :  the  chief  advantage  of 
which  is,  that  it  retains  the  file  much  more  firmly 
than  it  can  be  held  in  the  fingers.  These  carriers 
are  made  with  a  variety  of  curves,  to  accommodate 
different  positions.  There  is  also  a  great  variety  of 
small  file-point  instruments  for  dressing  down  fill- 
ings, the  more  important  of  which  are  represented 
in  Fig.  60. 


140 


INSTRUMENTS   FOR   FILLING 

Fiff.  60. 


m 


The  Use  of  the  File. — "When  a  separation  of  the 
teeth  is  requisite,  preparatory  to  filling,  it  is  fre- 
quently accomplished,  either  in  whole  or  in  part, 
with  the  file.  Principally,  in  such  a  case,  its  use 
is  restricted  to  finishing  and  smoothing,  after  the 
greater  portion  of  the  work  has  been  done  with 
the  heavy  cutting  instrument,  or  in  dressing  off  the 
thin,  attenuated  edges.  The  file  is  valuable  for 
removing  superficial  decay,  being  called  into  frequent 
requisition  in  caries  of  this  kind.  It  is  employed  to 
dress  off  roots  preparatory  to  the  insertion  of  pivot 
teeth,  for  which  purpose  it  is  required  to  be  of  a 
round  or  half-round  form.  It  is  used  for  dressing  off 
sharp   portions  or  edges  of  the  teeth,  that  may  be 


THE    FILE.  141 

injurious  to  the  soft  parts,  and  in  some  cases  for 
dressing  down  a  tooth  that  is  elongated.  In  finishing 
many  fillings  it  is  almost  indispensable.  It  was  for- 
merly used  to  some  extent  in  the  treatment  of  irregu- 
larity ;  but  for  this  purpose  it  has  been  abandoned. 

Mode  of  Using  the  File. — The  patient  should  be 
conveniently  seated,  with  the  head  on  a  firm  support, 
and  under  the  control  of  the  operator,  who  should 
occupy  a  position  at  the  right  of  the  patient,  in  most 
cases,  so  disposing  the  head  of  the  latter  as  to  give 
free  access  to  that  point  which  is  to  be  operated 
upon.  In  manipulating  with  the  file,  considerable 
skill  and  delicacy  are  requisite.  It  should  not  be 
held  with  a  stiff,  unyielding  grasp,  so  as  to  catch 
and  jar,  but  should  be  applied  with  a  gentle  pressure, 
and  drawn  across  the  tooth  with  a  free  and  flexible 
motion.  It  should  be  frequently  moistened,  and  not 
allowed  to  clog  with  the  filings,  being  kept  free  of 
these  by  repeated  applications  of  the  brush.  A 
sharp,  new  file,  with  a  quick,  light  movement,  will 
cut  far  more  rapidly,  and  less  unpleasantly  to  the 
patient,  than  one  that  is  dull  or  clogged,  applied 
with  a  heavy  pressure.  If  the  tooth  bone  is  sensi- 
tive, the  file  should  be  moistened  in  warm  water. 
For  cleansing  files  when  clogged  with  dentine,  the 
wire  brush  in  common  use  is  quite  efficient.  Every 
operator  should  have  one  at  hand.     The  form  of  a  file 


142  INSTRUMENTS    FOR    FILLING. 

may  be  changed  by  drawing  the  temper,  bending  it  as 
desired,  and  then  re-tempering  it.  It  is  better,  how- 
ever, to  have  them  made  of  the  proper  form  at  first. 

The  teeth,  while  being  filed,  should  be  supported 
by  the  fingers,  or  by  an  instrument  for  the  purpose  ; 
or  a  cork  or  piece  of  soft  wood  may  be  inserted 
between  the  tooth  being  filed  and  the  teeth  of  the 
opposing  jaw,  and  the  pressure  thus  used  as  a  sup- 
port. The  tooth  being  sustained  in  this  manner, 
there  is  less  jarring  experienced  by  the  patient,  and 
less  liability  to  produce  irritation  of  the  periosteum. 
When  filing  the  anterior  teeth,  it  is  generally  better 
to  hold  the  file  in  the  fingers.  For  filing  the  incisors 
and  cuspids,  a  thin,  bevel-edged  file  is  to  be  pre- 
ferred. In  dressing  a  tooth  with  a  file,  the  last  that 
is  used  should  be  a  fine  one ;  after  the  application  of 
which,  the  surface  operated  upon  should  be  made  as 
smooth  as  possible  with  a  stone  and  burnisher,  or 
with  a  buff  and  rotten-stone. 

In  separating  teeth  with  the  file,  where  but  one  is 
decayed,  care  should  be  taken  not  to  cut  the  sound 
one.  For  this  purpose,  it  will  usually  be  necessary 
to  have  a  safe  sided  file — one  side  smooth  to  present 
to  the  sound  tooth ;  and  even  then  the  cutting  edge 
should  be  somewhat  beveled  from  the  safe  side,  that 
the  sharp  angle  of  that  edge  may  not  rasp  the  sound 
tooth ;  in  no  case  of  this  kind  should  a  square-edged 


THE    FILE.  143 

file  be  used.  In  cases  in  which  it  is  necessary  to 
file  teeth  that  are  somewhat  loose  in  the  sockets, 
and  whose  periosteum  is  in  a  state  of  irritation,  to 
build  up  a  wall  of  plaster  of  Paris  round  them,  per- 
mitting it  to  harden,  will  very  much  facilitate  the 
operation.  Perhaps  a  preferable  method,  in  some 
respects,  for  accomplishing  the  same  object,  is  to 
mould  softened  gutta-percha  to  the  tooth  and  the 
parts  about  it.  After  it  has  become  hard,  hold  it 
firmly  in  place  while  the  filing  is  accomplished. 
Either  of  these  methods  will  be  found  valuable  in 
cases  where  it  is  necessary  to  dress  off  a  considerable 
portion  from  the  end  of  one  or  more  of  the  inferior 
front  teeth.  There  are  some  teeth  upon  which  the 
use  of  the  file  is  hardly  admissible ;  as,  for  instance, 
those  which  are  highly  predisposed  to  inflammation 
and  sensitiveness  of  the  dentine.  The  teeth  of 
young  persons,  being  often  of  this  character,  should 
be  filed  with  great  caution ;  but,  in  general,  those  of 
adults  may  be  filed,  if  properly  done,  with  more 
freedom.  The  file  should  not  be  used  upon  the 
teeth  when  the  periosteum,  the  gums,  or  the  mucous 
membrane  is  diseased,  or  strongly  predisposed  to 
such  a  condition.  It  should  never  be  used  for  the 
correction  of  irregularity  of  the  teeth,  especially 
when  they  are  sound ;  nor  should  it  be  employed  to 
separate  sound  teeth  to  introduce  clasps. 


144 


INSTRUMENTS    FOR    FILLING. 


Filing  the  teeth  is  an  operation  against  which 
there  has  been,  and  still  is,  much  prejudice,  though 
without  sufficient  cause.  Whatever  injury  results 
from  this  operation,  is  from  the  imperfect  manner 
in  which  it  is  performed,  and  from  subsequent 
neglect  of  the  tooth  which  has  been  subjected 
to  it.  A  tooth  skillfully  treated  with  this  instru- 
ment, and  properly  cared  for  afterward,  will  not  be 
more  liable  to  deca}^  at  the  point  operated  upon  than 
at  any  other  where  the  dentine  may  be  exposed. 


I 


V 


CHAPTER  V. 

SEPARATION  OF  THE  TEETH. 

In  most  cases  of  proximal  decay,  the  teeth,  before 
the  operation  of  filling  can  be  performed,  must  be 
separated ;  though  cases  are  not  unfrequent  where 
the  space  between  them  is  sufficient  to  admit  of  free 
manipulation  without  this  preliminary.  An  imper- 
fect accomplishment  of  this  first  step  in  the  process 
of  filling  is  a  prolific  source  of  the  many  failures,  in 
proximal  cavities,  to  attain  to  efficient  and  durable 
results;  for  unless  this  step  be  thoroughly  performed, 
so  as  to  make  room  for  the  free  introduction  and 
use  of  the  various  instruments  requisite,  no  part  of 
the  work  can  be  complete.  Though  the  most  com- 
mon object  for  which  teeth  are  separated  is  to 
obtain  space  for  free  manipulation  with  the  instru- 
ments in  filling,  yet  there  are  various  other  objects 
for  which  they  have  been  separated,  but  many  of 
which  are  now  better  accomplished  by  other  means. 
It  is  sometimes  necessary  to  cut  away  more  than 
would  otherwise  be  requisite,  in  order  to  remove  thin, 
friable  edges  of  the  cavity,  so  as  to  obtain  sufficiently 


146  SEPARATION    OF    TUE   TEETH. 

firm  borders.  Teeth  are  in  some  instances  separated 
for  the  introduction  of  clasps — a  practice  always  to 
be  deprecated,  since  it  usually  proves  highly  injurious. 
Though  the  practice  was  once  very  common,  yet 
most  if  not  all  the  best  operators  have  now,  with 
good  reason,  abandoned  it  altogether.  At  one  time, 
too,  it  was  a  general  practice  to  separate  the  teeth 
with  the  file  to  relieve  a  crowded  condition ;  but  this, 
also,  has  been  abandoned. 

There  are  two  methods  of  separating  the  teeth : 
the  one,  to  cut  away  a  portion ;  the  other,  to  force 
apart  by  pressure,  acting  upon  one  or  more  teeth,  as 
the  circumstances  admit.  Formerly,  all  separations 
were  effected  with  the  file,  and  this  of  very  crude 
form  and  cut,  by  which  instrument,  especially  in 
unfavorable  cases,  much  injury  has  been  done. 
Though  the  file  is  a  valuable  instrument,  one  that 
none  other  could  supply,  yet,  for  removal  of  any 
considerable  portion  of  dentine,  it  is  not  to  be  recom- 
mended. Its  action  upon  inflamed  dentine  is  exceed- 
ingly painful,  besides  being  tedious  and  wearisome  to 
patient  and  operator ;  it  is  also  liable  to  irritate  the 
periosteum,  and  to  increase  inflammation.  When  a 
separation  is  to  be  made  that  requires  the  removal  of  a 
considerable  portion  of  the  tooth,  the  chisel,  or  heavy 
cutting  instruments,  illustrated  on  pages  102  and 
103,  are  to  be  preferred.    These,  if  of  the  proper  form 


SEPARATION    OF   THE    TEETH.  147 

and  temper,  and  in  good  condition,  are  very  efficient 
for  the  purpose,  performing  the  work  far  more  rapidly 
than  the  file,  and  far  less  unpleasantly  to  the  patient. 
They  effect  the  removal  of  sensitive  dentine  with  but 
little  or  no  pain,  and  without  liability  to  increase  the 
inflammation,  or  to  produce  irritation  or  disease  of 
the  periosteum.  The  force  of  these  instruments  is 
sustained  by  the  entire  attachment  of  the  tooth,  their 
pressure  being  applied  almost  in  a  line  with  its  axis. 
Besides,  by  their  use,  the  contiguous  teeth  are  not 
liable  to  injury,  as  by  the  use  of  the  file  they  often  are. 
The  manipulation  with  these  instruments  is  very 
simple.  For  separating  front  teeth,  the  instrument 
is  firmly  grasped  in  the  hand,  the  thumb  placed  on 
the  points  of  the  teeth,  and  the  edge  applied  at  the 
point  or  crown  surface  of  the  tooth  from  which  the 
portion  is  to  be  removed,  and  pressed  gradually 
toward  the  gums,  but  not  thrust  into  the  interval  as 
a  wedge  before  it  has  freely  cut  its  way.  In  this 
manner,  as  much  of  the  dentine  as  it  is  desirable  to 
remove  is  cut  off  in  a  few  moments.  This  class  of 
instruments  is  invaluable  for  forming  the  V-shaped 
spaces  between  the  bicuspids  and  the  molars  that 
have  been  popular  with  many  operators,  but  are 
pointedly  condemned  by  others.  It  requires  a  pro- 
longed use  of  the  file  to  make  these  separations  pro- 
perly; and  hence  the  practice  of  attempting  to  fill 


148 


SEPARATION    OF   THE   TEETH. 


proximal  cavities  without  any  separation  at  all,  by 
operating  through  a  small  opening  at  the  crown  angle 
of  the  tooth,  or  a  small  hole  drilled  through  its  outer 
or  inner  portion.  With  the  heavy  cutting  instru- 
ments, points  upon  the  teeth  that  the  file  cannot 
touch  are  approached  and  operated  upon  with  facility. 
Another  method  of  effecting  the  same  kind  of  sepa- 
ration is,  by  the  use  of  the  corundum  disks,  used 
with  the  dental  engine. 

The  profession  is  indebted  to  Dr.  Robert  Arthur 
for  devising  and  rendering  practicable  this  very  valu- 
able appliance. 

These  disks,  as  seen  in  the  following  illustration, 
are  made  of  various  forms,  suitable  to  meet  all  cases. 


Fig.  61. 


For  using  the  disks,  carriers  have  been  devised 
and  made.  These  should  possess  three  qualities,  viz. : 
ready  adjustment  to  the  hand-piece  of  the  engine ; 
facility  of  attachment  and  release  of  the  diskj  and 
the  easy  change  of  the  disk  to  any  desired  angle  with 
the  shaft  containing  it.     That  invented  by  Dr.  Geo. 


SEPARATION   OF   THE   TEETH. 


149 


H.   Gushing  possesses  these  qualities  in  a  marked 
degree,  and  is  very  effective. 

The  dotted  lines  in  the  figure  show  the  angular 
range  of  movement  of  the  disk  upon  its  shaft. 

Fig.  62. 


For  convenience  and  safety  in  using  the  disk,  a 
shield  or  covering  is  adapted  to  it  that  effectually 
protects  all  parts  except  that  operated  upon. 


Fig.  63. 


By  means  of  this  instrument,  separations  of  little 
more  than  a  mere  opening  to  the  largest  V-shaped 
space  can  be  readily  made,  and  it  is  claimed  with 
equal  if  not  greater  ease  to  the  patient  than  by  any 
other  method. 

Skill  and  experience  are  required  for  their  facile  use. 

It  is  claimed  that  the  use  of  the  disk  will 
largely  supersede  that  of  the  file  for  separating  teeth. 

But  the  method  of  separation  by  pressure  is  in 


150  SEPARATION  OF  THE  TEETH. 

many  cases  to  be  preferred,  especially  in  the  case  of 
anterior  teeth,  whose  natural  form  it  is  important  to 
preserve. 

Till  within  a  comparatively  recent  period,  it  has 
been  the  general  practice  to  separate  by  gradual  pres- 
sure ;  and  it  is  even  yet  the  favorite  method  with 
some  operators.  But  in  almost  all  cases  where 
separation  is  to  be  made  by  pressure,  it  can  be  done 
at  once  quite  as  well,  if  not  better,  than  to  prolong 
the  process  through  several  days ;  there  is  economy 
of  time,  and  the  patient  has  far  less  to  endure,  and 
there  is  less  liability  of  doing  injury  to  the  teeth  or 
the  parts  about  them. 

The  anterior  teeth,  or  those  of  single  roots,  yield 
very  readily  to  a  strong  separating  force,  applied  in 
the  form  of  a  wedge,  notwithstanding  the  teeth  may 
all  be  in  contact  with  each  other ;  though  in  some 
bases  the  teeth  are  so  firmly  set,  and  the  parts  about 
them  so  dense  and  unyielding,  that  it  is  with  great 
difficulty  they  can  be  moved,  without  too  much 
violence  to  the  parts.  It  is  not  generally  practicable 
to  attempt  to  separate  the  molar  teeth  by  pressure. 

The  method  of  effecting  immediate  separation  is 
very  simple ;  it  consists  in  forcing  a  wedge  of  some 
fine-grained  wood  of  medium  resistance — orange  or 
box  wood — between  the  teeth  to  be  separated,  either 
by  pressure  with  the  hand,  or,  better,  by  the  blows 


SEPARATION    OF   THE    TEETH.  151 

of  a  mallet.  The  wedge  should  be  driven  in  at  the 
necks  of  the  teeth ;  before  this,  however,  a  shield- 
wedge  should  be  put  in  between  the  necks  of  the 
teeth  against  the  septum  of  gum ;  it  should  be  of 
such  form  as  to  retain  its  position  while  the  chief 
wedge  is  being  driven  in ;  and  when  they  are  very 
firm,  an  assisting  wedge  may  be  used,  inserted  be- 
tween the  points  of  the  teeth,  and  receiving  strokes 
alternately  with  the  other.  The  assisting  wedge 
should  be  of  very  dense  wood,  and  driven  in  with 
great  care,  for  its  leverage  upon  the  teeth  is  very 
great.  When  the  required  space  is  obtained,  the 
wedge  at  the  necks  of  the  teeth  should  be  driven 
tightly  in,  and  the  other  withdrawn.  If  all  the  teeth 
in  the  vicinity  of  those  to  be  separated  stand  in  con- 
tact, the  resistance  to  separation,  whether  by  imme- 
diate or  gradual  effort,  will  be  greater. 

Two  forms  of  appliances,  denominated  separators, 
invented  by  Dr.  Jarvis,  are  very  valuable  aids  in  the 
separation  of  the  teeth.  The  one  is  for  separating 
the  anterior  and  the  other  the  molar  teeth.  The 
former  is  described  as  consisting  of  two  wedges  ap- 
proaching and  passing  each  other ;  being  thus  drawn 
together  by  a  thumb-screw,  making  gradual  and 
prompt  separation  where  it  is  applied. 

Its  operation  is  much  more  acceptable  to  the  patient 
than  that  of  the   ordinary  wedge  driven  with  the 


152  SEPARATION  OF  THE  TEETH. 

mallet.  It  will  be  found  useful  in  making  room  for 
passing  rubber-dam  between  crowded  teeth.  It  may 
also  be  used  to  advantage  in  connection  with  the 
wedges. 

Fig.  64. 


That  for  the  molars  consists  of  a  properly-formed 
piece  of  steel,  bent  upon  itself,  with  the  ends  formed 
to  fit  the  outer  and.  inner  portions  of  the  proximate 
surfaces  of  two  adjoining  crowns. 

These  jaws  are  forced  apart  by  the  action  of  a 
screw,  which  passes  through  one  and  against  the 
other. 

This  form  is  applicable  to  all  the  bicuspids  and 
molars.  It  does  not  touch  the  gum  or  injure  the 
teeth,  neither  does  it  cause  much  pain. 

The  appliance  may  remain  on  the  teeth  in  some 
cases  while  an  operation  is  being  performed ;  other- 
wise a  wooden  wedge  should  be  inserted  between  the 
teeth.     It  is  represented  by  the  following  figure. 

The  rapidity  with  which  the  operation  may  pro- 
ceed, and  the  extent  to  which  it  may  be  carried, 
will  be  determined  by  the  tolerance  of  the  parts  to 
the  movement,  w^iich  should  not  be  greater  than  the 
elasticity  of  the  tissues  will  permit;  not  the  slightest 


SEPARATION  OF  THE  TEETH.  153 

laceration  or  rupture  should  be  made ;  again,  great 
care  should  be  observed,  lest  strangulation  of  the 
vessels  that  enter  the  roots,  pass  to  and  supply  the 

Fisr.  65. 


pulp,  be  effected ;  this  would  be  far  more  liable  to 
occur  in  the  teeth  of  young  persons,  or  before  matu- 
rity. There  is  in  adults,  however,  a  great  diversity 
in  their  susceptibility  to  injurious  influences. 

Many  operators  still  prefer  gradual  separation  by 
pressure.  In  order  to  secure  the  most  successful 
results,  the  conditions  of  the  parts  should  be  strictly 
observed.  The  gums,  periosteum,  etc.,  should  be  in 
a  healthy  condition;  for  much  injury  may  be  done 
by  attempting  to  separate  teeth  by  pressure,  when 
the  contiguous  parts  are  in  an  irritable  state.  In 
persons  of  a  neuralgic  diathesis,  in  those  whose  vital 
energy  is  weak,  and  particularly  in  those  whose  con- 
stitutional tendency  is  inflammatory,  this  operation 
is  scarcely  admissible.  If,  in  such  cases,  it  is  at- 
tempted at  all,  it  should  be  proceeded  with  very 
carefully  and  gradually,  and  should  be  preceded  by 
constitutional  treatment.     There  are  many  cases  in 


154  SEPARATION    OF   THE    TEETH. 

which  it  is  best  to  make  the  separation  partly  by 
pressure,  and  then  to  complete  it  by  dressing  off  the 
thin,  friable  edges  of  the  cavity  with  the  cutting 
instrument  or  file.  "Whether  the  process  is  to  be 
wholly  or  only  partly  accomplished  by  pressure, 
should  be  determined  beforehand. 

Various  materials  have  been  employed  for  sepa- 
rating the  teeth  by  gradual  pressure,  the  chief  of 
which  are  cotton,  wood,  India  rubber,  and  ligatures. 
The  condition  and  character  of  the  parts  to  be  ope- 
rated upon  will  indicate  the  material  best  adapted 
in  any  given  instance.  In  a  good  constitution,  with 
the  teeth  firmly  set,  and  the  contiguous  parts  healthy, 
wood  or  India  rubber  may  be  applied ;  but  in  cases 
of  an  opposite  character,  a  more  yielding  and  tract- 
able material  is  indicated.  The  degree  of  pressure 
to  be  applied  and  continued  will  be  determined  by 
the  susceptibility  of  the  parts  to  irritation.  Soreness 
usually  occurs  in  a  few  hours  after  the  introduction 
of  the  material.  The  pressure  should  be  gradual  and 
constant,  slight  at  first,  and  increased  in  force  as  the 
patient  will  bear ;  the  increase  being  made  every  day, 
and  continued  till  ample  space  is  obtained.  The  time 
necessary  for  the  completion  of  this  process  is  from 
ten  to  twelve  days ;  only  one  separation  should  be 
made  at  a  time.  The  teeth  should  be  retained  apart 
till  the  soreness  has  abated,  before  the  operation. 


SEPARATION  OF  THE  TEETH.  155 

If  not  thus  retained  too  long,  they  will  return  to 
their  former  position.  It  is  by  some  supposed  that 
separation  by  pressure  is  admissible  only  in  the  case 
of  the  young,  or  those  under  thirty  years  of  age.  It 
is  true  that  they  are  the  most  susceptible ;  but  the 
operation  is,  under  favorable  circumstances,  proper 
at  any  age. 


CHAPTER  VL 


FILLING    TEETH. 


The  operation  of  filling  teeth  is  an  interesting  and 
important  one,  requiring  for  its  successful  accomplish- 
ment peculiar  talent  and  large  experience.  It  is  the 
only  means  as  yet  ascertained  of  completely  effecting 
the  object  for  which  it  is  employed,  namely,  arrest  of 
decay  and  preservation  of  the  organs.  Therapeutic 
agents  avail  but  little  here,  so  low  is  the  organization, 
and  so  feeble  the  vital  power.  Nature,  so  efficient  in 
more  highly-organized  structures,  does  comparatively 
little  in  disease  of  the  teeth  toward  arrest  or  res- 
toration. Yet,  on  the  other  hand,  these  organs  are 
less  liable  to  decomposition  by  the  action  of  foreign 
substances ;  indeed,  well-organized  enamel  is  almost 
invulnerable  to  any  agents  to  which  it  is  ordinarily 
exposed.  The  dentine,  however,  is  more  easily  acted 
upon,  and,  when  there  is  defect  in  the  enamel,  is 
very  liable  to  injury. 

Scarcely  an  individual  in  our  country  arrives  at 
mature  age  with  a  perfect  set  of  teeth ;  indeed,  nine- 
tenths  of  our  people  have  decayed  teeth  at  an  early 


EXAMINATION.  157 

period  of  life.  Hence,  for  beautifying,  preserving, 
and  supplying  these  organs,  art  is  in  constant  requi- 
sition; and  in  these  respects  great  achievements 
have  been  made.  In  the  operation  of  filling  the 
teeth,  especially,  the  achievements  are  conspicuous ; 
and  here  is  scope  for  the  highest  skill.  Every  suc- 
cessive step  in  the  process  of  filling  a  tooth  demands 
a  complete  and  conscientious  application  of  the  most 
efficient  and  best  adapted  modes  and  appliances  of  the 
art.  In  the  following  remarks  it  is  proposed  to  analyze 
this  whole  process,  examining,  in  their  order,  the  vari- 
ous steps  necessary  to  be  taken,  and  endeavoring  to 
inculcate  the  true  methods  of  accomplishing  them. 

EXAMINATION. 

When  a  case  is  presented,  there  should  first  be  a 
thorough  examination,  since  by  this  all  the  subse- 
quent work  will  be  modified.  For  this  purpose  the 
proper  exploring  instruments  should  be  at  hand, 
which  should  consist  of  a  sufficient  number  and 
variety  of  fine  sharp-pointed  instruments,  so  formed 
and  curved  as  to  be  readily  brought  into  contact 
with  every  point  of  surface  of  the  crown  of  every 
tooth,  and  indicate  any  defect  that  may  exist. 

The  accompanying  cut  represents  the  common  and 
perhaps  the  best  forms  of  this  class  of  instruments. 


158 


FILLING   TEETH. 


In  addition  to  these,  mirrors,  reflectors  and  magni- 
fiers, when  properly  adjusted  and  skillfully  used,  are 
very  valuable. 


Fis.  66. 


i 


r 


r 


There  should  be  two  or  three  sizes  of  mirrors, 
adjustable  to  any  angle  requisite  to  reach  every 
point  in  the  mouth  efficiently. 

Reflectors  are  desirable  for  throwing  light  upon 
obscure  or  dark  points. 

Magnifiers  are  important  in  examination  of  the 
teeth,  to  bring  to  view  defective  points  that  would 
escape  detection  by  the  unassisted  eye.  Every 
operator  ought  to  have  at  hand  at  least  three  grades  of 

Fig.  67. 


these.    Mirrors  and  magnifiers  are  combined  to  some 
extent,   but   sufficient    amplification   and    definition 


EXAMINATION. 


159 


cannot  be  obtained  in  this  way  for  all  cases.     The 
common  mouth  mirror  is  shown  by  Fig.  67. 

Mirrors  and  reflectors  are  made  adjustable  upon 
the  finger  of  the  operator,  as  in 

Fig.  68. 


Reflectors  adjustable  on  the  rubber-dam  clamps 
serve  a  valuable  purpose,  and  should  always  be  at 
hand.     Shown  in 


Fiff.  69. 


They  are  also  attached  to  the  rubber-dam  clamps, 
which   makes,  for   many    cases,  a  very  convenient 


arrangement. 


Fig.  70  is  a  magnifier,  to  be  used  on  the  finger  of 
the  operator.  The  chief  use  of  the  magnifier,  how- 
ever, is  for  examination  rather  than  for  operating. 


IGO 


FILLING   TEETH. 


Tier.  70. 


The  points  to  be  noted  in  the  examination  are  as 
follows  : 

The  temperament ;  the  present  health ;  the  consti- 
tutional tendencies  ;  the  secretions, — the  saliva  and 
mucus ;  the  mucous  membrane  and  the  gums ;  the 
constitution  and  condition  of  the  teeth ;  the  num- 
ber of  them  remaining  in  the  mouth ;  the  number 
affected;  the  extent  and  nature  of  the  decay,  and 
the  character  of  the  agents  producing  it.  By  the 
examination  we  ascertain  how  to  proceed  in  the 
operation ;  if  much  or  but  little  labor  is  required ; 
whether  the  operation  will  be  a  simple  or  a  difficult 
one ;  and  if  difficult,  what  circumstances  render  it 
so ;  and,  besides,  some  conclusion  is  arrived  at  in 
regard  to  the  precise  means  to  be  employed  for 
obtaining  the  desired  result,  as  w^ell  as  the  perma- 
nency of  that  result. 


OPENING.  161 

OPENING. 


The  next  step  is  to  open  the  cavity  of  decay,  so 
that  it  may  be  approached  and  operated  upon  at  all 
points.  The  particular  manner  of  performing  this  is 
determined  by  the  extent  of  the  decay,  and  its  posi- 
tion upon  the  tooth.  In  all  cases  the  opening  should 
be  such  as  to  give  free  access  to  all  parts  of  the 
cavity,  for  effectually  removing  the  decayed  portion, 
for  perfectly  forming  the  cavity,  and  for  introducing, 
thoroughly  consolidating  and  finishing  the  filling.  In 
central  crown  cavities  of  the  molars  and  bicuspids, 
the  projecting  or  pendent  portions  of  enamel  should 
be  cut  away.  There  are  cases,  however,  where  such 
portions  are  firm  and  not  liable  to  be  broken,  and 
where  they  can  be  well  sustained  by  filling  under,  in 
which  it  is  admissible  to  leave  some  projection.  This 
is  true  of  only  those  teeth  which  are  of  good,  firm 
texture.  There  are  two  objections  to  these  abrupt 
projections  of  enamel :  it  is  very  difficult,  and  in 
many  cases  impossible,  to  fill  perfectly  beneath  such 
portions ;  and  again,  they  are  liable  to  be  broken 
down  during  mastication. 

For  opening  up  these  cavities,  in  many  cases  the 
bur  drill  alone  will  be  quite  sufficient ;  those  of  dif- 
ferent sizes  being  employed,  to  open  up  the  orifice 
gradually,  so  that  too  much  violence  may  not  be  done 


162 


FILLING    TEETH. 


to  the  teeth.  In  all  very  small  cavities,  the  bur  is 
all  that  is  required,  except  in  decayed  fissures,  and 
for  these  the  fissure  bur  is  almost  indispensable. 

In  cases  where  the  decay  is  more  extensive,  and 
the  cavity  larger,  the  chisel  or  heavy  cutting  instru- 
ment, in  connection  with  the  drill,  will  be  found  very 
useful.     Fig.  71  represents  valuable  forms  of  these 

instruments. 

Fi-.  71. 


Fig.  8,  page  lOH,  represents  instruments  for  this 
purpose,  of  various  forms  and  sizes ;  they  may  be 
used  either  with  hand  force  or  the  mallet.  In  cases 
where  much  cutting  is  required,  the  latter  method  is 
preferable,  being  more  rapid  in  execution,  and  less 
objectionable  to  the  patient. 

The  fine  file  or  bur  should  always  follow  the  use 
of  the  chisels,  to  give  a  smooth  and  even  surface  to 
the  part  upon  which  the  cutting  has  been  made. 

REMOVAL   OF    DECAY. 

After  the  cavity  is  opened,  the  next  step  in  order  I 

is  the  removal  of  the  decayed  dentine.   As  a  general 


■     REMOVAL   OF   DECAY.  163 

rule,  this  should  be  entirely  removed.  There  is, 
however,  some  variety  of  opinion  upon  this  subject. 
This  difference  of  opinion  is  in  regard  to  cases 
where  an  entire  or  a  partial  decomposition  of  the 
dentine  has  taken  place  quite  to  the  pulp,  where,  by 
its  removal,  the  pulp  would  be  exposed.  It  is  main- 
tained by  some  that  decayed  dentine  affords  a  better 
protection  to  the  pulp  than  any  artificial  covering ; 
and  hence  it  is  better  to  let  it  remain,  since  its 
adaptation  is  more  complete ;  and  it  is  not  in  every 
sense  a  foreign  substance. 

On  the  other  hand,  it  is  contended  that  the 
decayed  dentine,  being  in  an  abnormal  condition, 
will  irritate,  and  in  many  cases  ultimately  destroy, 
the  pulp.  And  again,  that  there  is  danger  of 
making  undue  pressure  upon  the  pulp,  in  filling  on 
such  softened  portion. 

In  many  cases  it  is  maintained  that  partially 
decomposed  dentine  will  become  dense  again,  if 
protected  from  the  influence  of  foreign  agents  that 
decompose  it.  This  sometimes  would  seem  to  be 
true.  For  in  some  cases  where  fillings  have  been 
introduced  into  cavities,  at  the  bottom  of  which  a 
portion  of  softened  dentine  covered  the  pulp,  on 
removing  them  in  from  one  to  five  years  afterward, 
all  parts  of  the  cavity  were  found  to  be  equally  and 
normally  dense.     This,  perhaps,   would   occur  only 


1(34  FILLING    TEETE. 

in  o-ood  constitutions,  and  under  favorable  circum- 
stances ;  but  with  such  constitutions  and  circum- 
stances, where  the  softening  is  not  too  extensive, 
and  the  decomposition  but  partial,  it  may  be  per- 
mitted to  remain,  with  a  strong  probability  of  a 
favorable  result.  This  would  certainly  be  better 
than  to  cut  it  all  away,  and  expose  and  perhaps 
wound  the  pulp,  and  then  endeavor  to  cover  it  with 
some  wholly  foreign  material  that  would  not  be 
perfectly  adapted  to  it,  that  would  press  a  little  too 
hard  at  one  point,  and  not  touch  at  another,  and  that 
would  be  quite  as  liable  to  be  pressed  down  on  the 
pulp  ks  the  softened  dentine. 

In  this  discussion,  much  depends  upon  the  point 
whether  partially  decomposed  dentine  can  retain  its 
vitality.  This  it  is  not  now  proposed  to  consider. 
There  are  some  particulars  in  regard  to  the  removal 
of  decay,  however,  about  which  there  is  no  diversity 
of  opinion :  first,  that  all  decomposed  dentine  should 
be  removed  from  all  parts  of  the  cavity,  where  the 
pulp  would  not  be  exposed  or  injured  thereby ;  and 
that  in  all  cases  it  should  be  entirely  removed  from 
the  lateral  walls  of  the  cavity,  and  especially  from 
the  vicinity  of  the  orifice.  Even  discolored  dentine 
should  be  removed  from  this  part,  unless  weakening 
of  the  borders  or  walls  would  thereby  be  occasioned. 

Dentine    often   becomes    changed   in   color   when 


I 


REMOVAEf   OF    DECAY.  165 

there  is  no  apparent  decomposition ;  such  portion  is 
usually,  though  not  always,  without  vitality.  It  is 
not  important  to  remove  such  changed  portion, 
except  for  the  appearance  of  the  tooth ;  it  will 
produce  no  change  upon  the  living  or  normal  part 
beyond  it ;  and  it  is  better  material  to  be  in  contact 
with  the  living  part  than  any  metal  of  which  a 
filling  may  be  made. 

Decayed  dentine  is  readily  removed  with  the 
excavators.  In  any  given  case,  such  instrument 
should  be  selected  as  would  be  best  adapted  for  the 
purpose,  as  well  in  regard  to  size  and  the  form  of 
its  edge,  as  to  the  curvature,  or  inclination  of  its 
shaft.  The  edge  of  the  instrument  should  come 
upon  the  walls  of  the  cavity  at  such  an  angle  as  to 
accomplish  the  work  most  efficiently.  It  should  be 
very  sharp,  and  pressed  firmly  to  the  bottom  of  the 
decay  at  one  side,  so  as  to  remove  the  principal  part 
at  one  cut.  So  far  as  possible,  the  direction  of  the 
cutting  should  always  be  from  the  nearest  point  of 
pulp  exposure,  toward  the  orifice  of  the  cavity.  With 
the  proper  instrument,  and  that  in  the  right  condition, 
all  the  decay  should  be  removed  from  any  cavity 
by  a  few,  firm,  steady  strokes.  By  this  method 
less  pain  is  caused  the  patient,  and  the  work  of  the 
operator  is  facilitated.  It  is  intolerable  to  think  of 
being  subjected  to  an  awkward,  clumsy  hand,  with 


IGG  FILLING   TEETH. 

a  dull,  ill-shaped  excavator,  scratclimg  upon  the 
surface  of  a  decayed  tooth,  for  a  length  of  time, 
apparently  to  the  patient  interminable. 


FORMING   CAVITIES. 

The  next  step  in  the  operation  is  the  formation  of 
the  cavity.  By  this  the  cavity  is  so  formed  that  it 
will  well  receive  and  retain  the  jfilling  w4ien  properly 
introduced.  In  very  few  cases  is  the  cavity  of 
proper  form  when  the  decay  is  removed ;  but  in 
almost  every  instance  more  or  less  of  the  solid 
dentine  must  be  removed  to  secure  a  proper  form 
to  the  cavity.  Much  time,  patience  and  labor  are 
required  of  the  operator  for  the  proper  accomplish- 
ment of  this  part  of  the  work,  and  much  endurance 
on  the  part  of  the  patient.  In  this  part  of  the 
work  several  particulars  require  consideration.  The 
great  object,  however,  is  to  give  to  the  cavity  such 
a  form  as  will  secure  the  most  perfect  adaptation  of 
the  filling  to  every  point,  and  its  permanent  retention 
in  place.  The  cutting  for  the  formation  of  the 
cavity  should  be  accomplished  with  the  least  possible 
loss  of  healthy  dentine  ;  this  is  a  point  upon  which 
good  judgment  should  be  exercised.  The  strength 
of  the  walls  of  the  cavity,  and  the  ability  of  the 
parts  to  withstand  the  pressure,  both  in  the  intro- 


FORMING    CAVITIES.  1G7 

duction  and  consolidation  of  the  filling  and  in  the 
act  of  mastication,  should  be  well  noted.  It  may  be 
regarded  as  a  rule  from  which  there  should  scarcely 
ever  be  a  departure,  that  the  enamel  should  never  be 
encroached  upon,  through  the  dentine,  in  excavating 
to  give  form  to  a  cavity.  When  there  is  but  a  lining 
of  dentine  at  any  given  point  on  the  enamel,  after 
the  decay  is  removed,  it  should  remain  for  the 
preservation  of  the  enamel ;  it  should  not  be  cut 
through  either  by  pits  or  by  grooves,  much  less 
should  any  considerable  portion  be  removed. 

There  are  cases  occasionally  in  which  the  dentine 
is  wholly  decayed,  and  its  removal  lays  bare  the 
enamel ;  when  such  a  case  occurs,  the  enamel  should 
be  retained  in  as  perfect  a  condition  as  possible,  and 
no  attempt  made  to  form  pits  or  grooves  in  it.  The 
reason  for  this  is  found  in  the  friability  of  the 
enamel. 

It  may  be  regarded  as  an  axiom,  that  where  it  is 
necessary  to  cut  the  healthy  dentine  to  give  proper 
form  to  the  cavity,  it  should  be  done  at  that  part  of 
the  cavity  where  the  tooth  will  suffer  least  from  the 
loss.  The  precise  point  and  amount  of  cutting  will 
be  determined  by  the  form  and  size  of  the  cavity, 
and  the  amount  of  solid  dentine  remaining  after  the 
decay  is  removed. 

In  small  cavities  where  there  is  sufficient  material 


1G8  FILLING    TEETH. 

to  work  upon,  the  object  is  to  give  the  cavity  a 
regular  form,  and  make  the  retaining  points  where  it 
is  most  convenient. 

In  large  cavities,  where  one  side  of  the  tooth  is 
weak,  places  must  be  selected  for  making  the  retain- 
ing points,  that  will  least  affect  the  weak  point. 
Frequently,  in  proximal  decays  of  the  anterior  teeth, 
the  labial  and  palatal  walls  are  friable,  and  would  be 
easily  broken ;  much  cutting  upon  such  walls  would 
not  be  admissible.  Again,  the  decay  often  extends 
toward  the  point  of  the  tooth,  down  to  the  union  of 
the  labial  and  palatal  plates  of  the  enamel ;  in  cases 
of  this  kind,  all  that  can  be  done  at  this  point  is  to 
remove  the  decay ;  and  fracture  will  sometimes 
occur  even  in  accomplishing  this. 

In  some  instances,  as  in  the  crown  cavities  of  the 
molars,  the  cavity  will  be  nearly  or  quite  of  proper 
form  when  it  is  perfectly  opened  up,  and  the  decay 
all  .removed.  This  is  the  case  when  the  decay  is 
confined  to  a  simple  perforation  of  the  dentine, 
without  any  considerable  lateral  extensions.  In 
proximal  cavities  there  is  always  more  or  less  exca- 
vation of  the  solid  dentine  required,  to  give  the 
cavity  proper  form. 

There  is  no  definite  rule  for  the  formation  of 
cavities,  that  will  be  applicable  in  all  cases.  The 
form  will  be  modified  by  the  tooth,  the  position  of 


FORMING    CAVITIES,  169 

the  decay  upon  it,  the  extent  and  ramifications 
of  the  decay,  and  the  manner  in  which  it  is  to  be 
filled.  It  is  given,  by  some,  as  a  rule,  that  the 
depth  of  a  cavity  should  be  equal  to  its  least 
diameter.  This  is  a  direction,  however,  of  no 
general  application,  for  many  canities  will  be  much 
deeper  than  the  greatest  diameter,  as  in  crown 
cavities  of  the  molars;  and  the  reverse  will  often 
occur,  as  in  labial  cavities  of  the  superior  incisors, 
and  in  proximal  cavities  of  the  molars,  in  which  it 
would  be  impossible  to  make  anything  like  an 
approach  to  this  rule,  without  exposing  the  pulp, 
and  even  cutting  through  its  chamber. 

A  general  direction,  and  one  that  we  think  good, 
and  applicable  in  many  cases,  especially  in  crown 
cavities  of  the  molars,  and  in  almost  any  of  the 
deep  perforations  by  decay,  is  to  make  the  walls 
of  the  cavity  as  nearly  as  practicable  parallel  with 
one  another.  This  rule  is  applicable  in  almost  all 
small  cavities. 

In  medium  or  large-sized  cavities,  it  is  admissible 
to  leave  them  slightly  larger  at  the  bottom  than  at 
the  orifice,  if  circumstances  require ;  a  large  cavity 
of  this  form  can  be  perfectly  filled,  when  a  small 
one  could  not,  from  the  fact  that,  in  the  former 
there  is  more  room  to  operate  in  introducing, 
adapting  and  consolidating  the  filling. 


170  FILLING    TEETH. 

Cavities  that  are  larger  within  than  at  the  orifice, 
should  have  their  walls  perfectly  plain,  smooth  sur- 
faces, free  from  transverse  grooves  or  depressions, 
so  that  the  gold  may  be  accurately  adapted  to  them. 

It  is  sometimes  necessary  to  leave  a  cavity  slightly 
larger  at  the  orifice  than  at  the  bottom.  This  may 
be  done  by  a  diverging  inclination  of  the  wall  of 
one  or  more  sides  of  the  cavity.  When  there  is  an 
inward  inclination  of  the  w^all  at  one  side  of  the 
cavity,  the  general  form  may  be  such  as  to  retain 
a  filling  perfectly,  for  there  may  be  two  opposite 
sides  parallel,  or  even  divergent ;  in  that  case,  the 
axis  of  the  cavity  will  not  be  in  the  direction  of  the 
centre  of  the  crown. 

Two  opposite  sides  may  converge  and  the  others 
diverge,  and  a  filling  be  retained  firmly.  When  two 
contiguous  sides  have  the  same  converging  inclina- 
tion, making  the  orifice  larger  than  the  interior,  if 
the  walls  are  smooth,  plain  surfaces,  a  filling  will  not 
be  retained ;  but  retaining  points  may  be  made  by 
forming  transverse  grooves,  or  pits  upon  them,  and 
by  this  means  the  filling  be  firmly  retained.  As  a 
general  rule,  it  will  be  necessary,  when  the  orifice  is 
larger  than  the  cavity  wdthin,  to  make  grooves  or 
pits  on  the  walls.  For  this  purpose  the  diamond 
point  excavator  is  invaluable. 

If  the  cavity  is  large,  and  the  walls  near  the  orifice 


FORMING   CAVITIES.  171 

thin,  and  liable  to  be  broken,  the  situation  of  the 
grooves  or  under-cutting  should  be  farther  within  the 
cavity  than  if  the  walls  are  firm  out  to  the  edge. 
Sometimes  it  is  best  to  make  little  pits  at  the  bottom 
of  such  cavities  for  retaining  points.  In  cases  where 
it  is  necessary  to  make  an  under-cutting,  one  or  two 
little  transverse  grooves  upon  one  side  will  be  suffi- 
cient, and  in  no  case  on  more  than  two  sides,  leaving 
the  others  perfectly  plain  surfaces. 

In  the  formation  of  retaining  points  in  difficult 
cavities,  there  is  considerable  diversity  of  practice — 
under-cutting  and  grooving  have  been  very  com- 
monly emplo3^ed.  Another  method  in  common  use 
is  that  of  drilling  little  holes  or  pits  into  the  dentine 
at  the  most  favorable  points,  these  taking  different 
directions.  This  kind  of  retaining  points  is  much 
better  calculated  to  answer  the  purpose,  in  filling 
with  crystal  gold,  or  cohesive  foil,  than  with  the 
ordinary  non-cohesive  foil  after  the  old  methods. 
When  these  perforations  are  made  at  different 
inclinations,  and  then  perfectly  filled  with  cohesive 
gold  of  any  kind,  the  filling  will  certainly  be  retained 
in  place.  For  making  these  perforations,  a  small 
square-edged  drill  is  the  proper  instrument. 

Such  retaining  points  are  seldom  or  never  required 
in  crown  cavities  of  the  molars ;  but  in  proximal 
cavities   they  are  frequently  employed   with   great 


172  FILLING   TEETH. 

advantage.  In  forming  them,  great  care  should  be 
exercised,  lest  the  pulp-chamber  is  encroached  upon 
by  the  instrument.  In  almost  all  cases,  the  proper 
point  for  forming  them  is  in  the  cervical  wall  of  the 
cavity. 

Some  operators  discard  any  definite  retaining 
points,  grooves,  or  angles,  but  aim,  instead,  to  give  a 
general  retaining  form  to  that  part  of  the  cavity  in 
which  the  fiUing  is  to  be  commenced,  and  upon  which 
reliance  is  to  be  placed  for  its  retention.  The  ad- 
A'antage  of  definite  retaining  points  is  two-fold :  first, 
to  facilitate  the  introduction  of  the  filling ;  and  second, 
its  more  certain  retention  after  it  is  in  position. 

Another  particular  to  which  attention  should  be 
given  is  the  border  of  the  orifice.  It  should  always 
be  an  object  to  secure  an  even,  smooth  and  stronrj 
border  to  the  orifice  of  the  cavity.  It  is  impossible 
to  make  a  good  finish  with  a  rough,  uneven  border ; 
the  filling  is  also  more  exposed  to  injmy  by  mastica- 
tion. The  integrity  of  a  smooth,  plain  surface  is 
retained  under  influences  that  would  break  up  and 
destroy  an  uneven  one.  It  is  also  very  desirable 
to  have  a  firm  margin;  to  obtain  this,  it  is  often 
necessary  to  cut  away  more  than  would  otherwise  be 
desirable.  A  smooth,  firm  border  should  not  be  sacri- 
ficed for  the  form,  and  especially  in  the  posterior 
teeth.     It  is  very  objectionable  to  some  persons  to 


FORMING   CAVITIES.  173 

have  the  perfect  form  of  the  front  teeth  marred  or 
changed;  but  it  should  be  remembered  that  even  a 
front  tooth  one-thh'd  cut  away,  and  so  filled  as  to  be 
permanently  preserved,  is  far  more  valuable  than  an 
artificial  one. 

Another  particular  that  should  always  be  observed, 
is,  to  obviate  all  acute  angles,  and  especially  when 
they  are  in  the  vicinity  of  the  orifice  of  the  cavity. 
These  are  seldom  or  never  found  in  proximal  cavities 
of  the  molars  and  bicuspids ;  occasionally  they  are 
found  in  proximal  cavities  of  the  cuspids,  and  fre- 
quently in  proximal  cavities  of  the  incisors,  par- 
ticularly at  that  part  of  the  cavity  next  to  the 
cutting  edge  of  the  tooth.  Such  angles  are  very 
often  found  also  in  crown  cavities  of  the  molars  and 
bicuspids,  where  there  is  an  extension  of  the  decay 
along  one  or  more  of  the  fissures  of  the  crown. 

It  is  difficult — almost  impossible — to  fill  perfectly 
a  sharp  angle,  and  hence  the  necessity  of  obliterating 
such  when  it  occurs.  This  may  be  done  either  with 
a  small  delicate  cutting  instrument  or  with  a  small 
bur  drill.  It  is  an  operation  requiring  great  care 
and  delicate  manipulation,  at  least  so  far  as  the  an- 
terior teeth  are  concerned.  When  a  sharp  angle 
occurs  in  the  proximal  cavities  of  the  front  teeth, 
it  is  usually  near  the  cutting  edge  of  the  tooth, 
just  at  the  union  of  the  labial  and  palatal  plates  of 


174  FILLING    TEETH. 

enamel.  A  small  chisel-shaped  instrument  is  very 
good  for  cutting  out  such  angles  :  indeed,  in  fissures 
of  crown  cavities  of  molars,  where  the  decay  extends 
backward,  the  straight,  chisel-shaped  instrument  is 
just  adapted  to  this  purpose ;  but  when  there  is  an 
anterior  extension,  the  instrument  should  be  curved 
to  almost  a  right  angle,  and  forced  down  by  pressure 
of  the  thumb  of  the  left  hand.  The  small  burs  and 
fissure  drills  represented  by  Figs.  20  and  22,  used 
with  the  dental  engine,  will  meet  the  requirements 
in  such  cases  with  great  facility.  Some  good  opera- 
tors recommend  a  slight  reaming  at  the  orifice  of  all 
cavities,  where  it  can  be  accomplished.  The  object 
of  this  is  two-fold  :  to  remove  the  sharp  angle  at  the 
orifice  of  the  cavity,  as  it  is  liable  to  be  fractured  or 
roughened  in  putting  in  the  filling;  and  to  give  a 
better  margin  to  the  filling.  In  making  this  bevel, 
the  bur,  if  one  is  used,  should  be  but  little  larger 
than  the  orifice  of  the  cavity.  The  cutting  should 
be  but  slight — just  sufficient  to  remove  the  sharp 
corners  ;  much  cutting  here  would  give  too  thin  and 
yielding  an  edge  to  the  filling. 

EXCLUSION    OF    MOISTURE. 

The  complete  and  certain  exclusion  of  saliva  and 
all  moisture  from  a  tooth  that  is  to    be  filled,  has 


EXCLUSION    OF   MOISTURE.  175 

ever,  till  within  a  comparatively  recent  period,  been 
a  great  desideratum.  A  great  many  appliances  and 
methods  have  been  employed  for  the  accomplish- 
ment of  this  object.  The  usual  method  was  to  pack 
about  and  around  the  tooth  upon  which  an  operation 
was  to  be  performed  napkins,  bibulous  paper,  spunk, 
etc.,  retained  in  place  by  holders.  These,  in  most 
cases,  were  effectual  but  for  a  short  time,  and  when 
the  flow  of  saliva  was  abundant,  constant  vigilance 
and  effort  were  necessary  to  secure  the  proper  ex- 
clusion of  moisture.  Quite  a  variety  of  instruments 
and  appliances  have  been  employed  for  holding  in 
place  these  various  paddings.  Some  of  them  were 
to  be  held  by  the  patient,  others  were  so  formed  as 
to  clamp  the  rolls  or  pads  firmly  in  place. 

None  of  these  appliances  had  reference  to  check- 
ing the  flow  of  saliva  by  compression  upon  the  mouths 
of  the  ducts ;  this,  however,  in  due  time  was  intro- 
duced. Various  appliances  and  adjustments  were 
made  with  this  object  in  view.  Pads  of  cloth, 
bibulous  paper,  spunk,  and  disks  of  pipe  clay,  were 
the  principal  things  used  for  this  purpose ;  they  were 
placed  and  held  firmly  an  the  mouths  of  the  ducts 
by  clamps,  springs,  &c.  A  good  degree  of  success 
was  in  this  way  attained  in  some  cases,  in  others  it 
is  impossible  to  close  all  the  ducts ;  and  in  almost 
every  instance  these  things  stimulated  an  excessive 


176  FILLING    TEETH. 

flow  of  mucus.  Filling  the  nioutli  in  the  manner 
just  described  was  always  objectionable  to  the 
patient,  and  in  many  instances  could  not  be  tolerated. 

In  addition  to  all  these  things,  various  pumps 
were  devised  for  removing  the  saliva  from  the 
mouth  as  it  accumulated,  all  of  which  Avere  more 
or  less  objectionable. 

All  these  modes  and  appliances  have  been  super- 
seded by  the  introduction  and  use  of  the  rubber 
dam  and  saliva  extractor.  For  the  former  of  these 
the  profession  is  indebted  to  Dr.  S.  C.  Barnum,  and 
for  the  latter  to  Dr.  J.  E.  Fisk. 

The  rubber  dam  is,  by  all  those  who  understand 
its  use,  justly  regarded  as  an  invaluable  boon.  It 
can  in  any  and  all  cases  be  applied  so  as  to  abso- 
lutely exclude  moisture  from  a  tooth  or  teeth  while 
being  operated  upon.  It  does  not,  however,  prevent 
the  free  flow  of  saliva  into  the  mouth,  and  in  most 
cases  this  occurs  to  a  very  objectionable  extent,  and 
either  the  patient  must  swallow  it, — and  with  the 
rubber  dam  in  place  very  few  can  do  this, — or  it  must 
overflow  from  the  mouth,  which  is  very  unsightly, 
inconvenient,  and  annoying,  or  it  must  be  drawn 
from  the  mouth. 

About  three  years  ago.  Dr.  Fisk  made  available 
the  principle  of  the  Gifford  injector,  devised  the 
saliva  extractor,  a  very  valuable  appliance   indeed ; 


EXCLUSION    OF    MOISTURE. 


177 


one  that  with  a  constant  stream  of  water  performs 
its  work  perfectly.  The  following  cut  gives  a  sec- 
tional view  of  it. 


Fig.  72. 


An  instrument  constructed  by  Dr.  George  B.  Snow 
for  the  same  purpose  gives  promise  of  great  useful- 
ness. In  principle  it  is  a  compromise  between  the 
Gilford  injector  and  the  syphon.  It  requires  for 
operation  but  a  small  amount  of  water — about  one 
quart  per  hour.  The  water  requisite  for  its  work- 
ing is  contained  in  a  reservoir  holding  about  two 
quarts. 

This  instrument  is  very  efficient  and  uniform  in 
its  operation.     It  is  shown  in  Fig.  73. 

With  either  of  these  appliances,  the  mouth  can  be 
kept  for  any  length  of  time  entirely  free  from  any 
excess  of  saliva. 

The  rapid,  easy  and  efficient  application  of  the 
rubber  dam  is  not  attained  without  some  manipula- 
tive skill  and  experience.  It  is  prepared  for  dental 
purposes  of  three  or  four  grades,  in  respect  to  thick- 
ness ;  the  thinnest  is  about  as  thick  as  a  sheet  of 


178 


FILLING   TEETH. 


1 


Fig-  73.  common  commercial  note  paper ;  the 
other  extreme  would  be  represented 
by  about  six-ply  of  the  same  paper. 

This  web  should  be  made  of  rub- 
ber of  the  finest  quality,  and  free 
from  all  foreign  substances.  Having 
selected  that  of  the  desired  thickness, 
cut  a  piece  six  inches  wide  and  from 
six  to  ten  inches  long ;  select  the 
proper  place  or  places  for  perforating 
it  for  the  teeth ;  for  this,  three  sizes 
of  punches  will  be  required  :  one  about 
a  line  and  a  half  in  diameter,  for  the 
molars ;  one  about  a  line  in  diameter, 
for  the  superior  incisors  and  bicuspids, 
and  one  half  a  line,  for  the  inferior 
incisors,  and  sometimes  for  small 
superior  incisors. 

These  punches  are  shown  in  Fig. 
74.  The  distance  between  the  holes 
in  the  cloth  should  be  from  one  line 
to  two  lines  and  a  half,  governed  by 
the  distance  between  the  necks  of  the  teeth  to  which 
it  is  to  be  applied. 

The  following  accessories  should  be  at  hand  and 
ready  for  use  before  beginning  its  application  to  the 
teeth : 


EXCLUSION    OF    MOISTURE. 


179 


Fiff.  74. 


Silk  Thread. — That  known  as  surgeons'  or  sad. 
dlers'  silk  is  well  adapted  to  the  purpose.  There 
should  be  at  least  two  sizes  of  this. 

For  some  cases  the  floss  silk  is  better  adapted 
than  the  thread.     These  should  always  be  at  hand. 

The  clamps  for  rubber  dam  are  indispensable ;  they 
are  of  various  forms  and  sizes,  and  are  now  made 
adapted  to  all  the  teeth ;  and  in  addition  there  is  quite 
a  number  of  extras  for  special  cases. 

The  following  cut  represents  the  set  for  the 
superior  teeth  of  the  right  side,  each  of  which  has 
been  formed  and  adapted  to  the  respective  tooth  upon 
which  it  is  to  be  used. 

There  are  in  the  full  set  thirty-two,  and  a  few  for 


180 


FILLING   TEETH. 


R.  S.,1 


B.  S.,  4. 


R.  S.,  5. 


Special  cases,  thus  making  by  far  the  most  complete 
and  efficient  series  of  these  clamps  ever  devised. 

The  profession  is  largely  indebted  to  Dr.  Delos 
Palmer  for  the  most  efficient  clamps  that  have  been 
in  use  for  several  years,  and  wholly  indebted  to  him 
for  the  very  perfect  set  represented  above. 

The  clamps  are  usually  placed  on  the  teeth,  after 
the  rubber-cloth  is  drawn  over  them,  for  the  pur- 
pose of  retaining  it  in  a  proper  position.  Often- 
times, however,  the  rubber  may  be  drawn  over  the 
clamp,  and  then  both  together  be  placed  upon  the 
tooth.  This  method  is  usually  employed  only  when 
one  tooth  is  to  be  protected. 

For  this  adjustment  upon  the  teeth,  clamp-forceps 
are  in  requisition.  They  are  so  formed  as  to  pass 
into  the  curve  of  the  clamp,  and  by  pressure  upon 
the  handles,  open  it  sufficiently  to  pass  on  to  the 
crown  of  the  tooth,  the  rubber  then  being  drawn 
under  the  jaws  of  the  clamp. 

Fig.  76  represents  the  clamp-forcep  in  common  use. 


EXCLUSION   OF   MOISTURE. 
Fig.  76. 


181 


182 


FILLING   TEETH. 


The  elastic  strap,  with  clamps  or  catches  attached, 
is  necessary  for  holding  away  the  upper  free  portions 
of  the  rubber-cloth  (Fig.  77). 

Fig.  77. 


The  weights,  also,  for  holding  out  of  the  way  the 
lower  free  portions  of  the  rubber-cloth,  are  impor- 
tant.    These  are  shown  in  Fig.  78. 

Various  sizes  and  forms  of  tvedges  will  be  required; 
these  should  be  prepared  beforehand,  or  they  may 
be  made  at  the  time  they  are  to  be  used;  their 
adaptation  to  the  peculiarities  of  the  case  in  hand 
rather  favors  this  course. 


EXCLUSION    OF    MOISTUKE. 


188 


Fig.  78 


Jarvis  separators  should  always  be  at  hand,  to 
press  apart  any  teeth  that  may  stand  so  firmly  in 
contact  as  to  prevent  the  rubber  from  passing  readily 
between  theai. 


Fig.  79. 


Having  now  come  to  that  point  when  the  rubber- 
dam  is  to  be  applied,  various  questions  and  consider- 
ations occur : 

First. — Upon  how  many  teeth  shall  the  dam  be 
placed  ? 

The  character  of  the  operation  will  determine  this. 
For  a  simple  crown  cavity  of  either  a  superior  or 


184  FILLING    TEETH. 

inferior  molar,  if  the  opening  of  the  mouth  is  capa- 
cious, the  embrace  of  one  tooth  may  be,  and  often  is, 
sufficient.  If,  however,  the  mouth  be  small,  or  the 
tooth  unfavorably  located,  two  or  even  three  teeth 
should  be  included,  even  for  such  a  cavity  as  just 
indicated.  For  filling  proximal  cavities,  two  or  more 
teeth  should  always  be  included,  and  more  fre- 
quently three  or  four.  The  difficulties  liable  to  occur 
from  the  embrace  of  an  insufficient  number  are  :  en- 
croachment of  the  cloth  upon  the  locality  of  the  ope- 
ration (the  size  of  the  mouth  and  its  behavior  will 
modify  this,  however),  and  the  liability  of  leakage 
about  the  last  teeth  included  in  the  embrace. 

A  sufficient  number  should  in  every  case  be  in- 
cluded to  meet  the  requirements,  and  no  more.  The 
practice  of  placing  the  rubber  upon  eight  or  ten 
teeth,  when  two  or  three  at  most  would  be  sufficient, 
should  not  be  encouraged  or  allowed.  It  is  a  waste 
of  time  for  the  operator  and  an  unnecessary  annoy- 
ance to  the  patient. 

In  the  application  of  the  dam,  if  it  is  to  be  put 
upon  two  or  more  teeth,  it  should  first  be  placed 
upon  that  tooth  which  is  most  accessible,  then  upon 
the  next  one,  and  so  on  till  all  the  selected  ones  are 
included.  As  the  rubber  is  drawn  over  the  crown  of 
each  tooth,  the  thread  or  floss  should  be  passed 
between  it  and  its  neighbor,  carrying  down  to  the 


EXCLUSION    OF   MOISTURE.  185 

margin  of  the  gum  the  rubber  that  is  between  the 
holes ;  this  process  should  follow  the  application  of 
the  rubber  to  each  tooth. 

The  rubber  will  often  pass  with  difficulty  between 
the  teeth,  either  because  of  firm  contact  or  because 
of  roughness  upon  the  proximate  surfaces  of  the 
teeth,  the  latter  sometimes  causing  tearing  of  the 
rubber.  To  meet  the  former  difficulty,  the  separ- 
ators (Fig.  79)  may  be  used,  and  sufficient  space 
readily  obtained  to  affi^rd  an  easy  passage  between  the 
teeth,  and'  a  A^ery  thin  saw  for  the  removal  of  the 
roughness ;  this,  however,  should  never  be  applied 
to  the  perfect  surfaces  of  the  teeth  ;  and  in  respect  to 
the  rubber,  moistening  it  with  a  solution  of  fine  soap, 
of  proper  consistence,  will  greatly  facilitate  its  pas- 
sage between  the  teeth. 

The  rubber  cloth  now  being  upon  the  teeth,  the 
elastic  band  with  its  clasp  should  be  attached  to  the 
upper  free  border  at  each  side,  and  drawn  round  the 
head  sufficiently  to  keep  them  out  of  the  way ;  then 
the  thread,  in  connection  with  a  small,  properly-formed 
instrument,  will  be  applied  for  turning  the  border  of 
the  rubber  about  each  tooth  down  beneath  the  margin 
of  the  gum,  the  thread  accomplishing  this  between 
the  teeth  and  the  instrument,  at  the  labial  and 
lingual  surfaces.  This  is  a  part  of  the  work  that 
should  be  carefully  and  thoroughly  performed  ;  the 


186  FILLING    TEETH. 

absolute  exclusion  of  the  moisture  depends  much  upon 
this.  Ligatures  are  sometimes  tied  tightly  round 
the  necks  of  the  teeth,  for  the  purpose  of  holding 
the  rubber  in  place  about  them. 

After  this,  the  wedges,  if  requii'ed,  should  be  in- 
troduced. The  objects  to  be  gained  by  these  are  : 
increase  of  space  between  the  teeth ;  to  retain  the 
septum  of  the  rubber  against  the  gum,  and  press  the 
gum  up  somewhat,  and  thus  effect  greater  security 
against  the  encroachments  of  moisture ;  and  to  pro- 
tect the  gum  from  injury  by  the  instruments  which 
are  to  be  subsequently  used. 

The  weights  should  now  be  applied  to  the  inferior 
borders  of  the  rubber,  in  such  a  manner  as  to  keep 
them  in  a  desirable  position.  With  the  rubber  dam 
thus  adjusted,  and  the  "  saliva  extractor"  in  proper 
order  and  in  place,  there  will  be  no  difficulty  with 
moisture  or  an  overflow  of  saliva  in  any  case,  and  the 
succeeding  steps  may  be  conducted  with  the  utmost 
security,  so  far  as  moisture  is  concerned. 

Some  operators  apply  the  rubber  dam  in  almost 
every  instance  prior  to  the  removal  of  decay  and  the 
formation  of  the  cavity  for  filling ;  and  doubtless  in 
many  cases  it  is  the  preferable  course,  the  only  ob- 
jection to  it  being  the  prolonged  inconvenience  to 
the  patient ;  but  for  this  there  is  perhaps  full  com- 
pensation,   in    the   greater    facility  afforded    in    the 


EXCLUSION    OF    MOISTURE. 


187 


remoA'al  of  decay  from  and  the  excavation  of  the 
cavity ;  with  the  entire  absence  of  saliva  and  moisture, 
the  work  can  be  effected  with  greater  rapidity  and 
precision ;  improper  cutting  is  less  liable  to  occur. 

After  the  rubber  dam  is  properly  adjusted,  it  is  an 
easy  matter,  with  bibulous  paper  or  some  similar  sub- 
stance, to  render  the  tooth  and  the  part  to  be  operated 
upon  thoroughly  dry.  Every  particle  of  debris,  cut- 
tings of  dentine,  etc.,  should  be  removed  from  the 
cavity  before  it  is  filled.  This  removal  may  be 
effected  by  the  small  scoop-shaped  instruments,  of 
which  there  should  be  three  or  four  sizes.  In  con- 
nection with  these,  the  '''chip  hlotver,''  or  warm  air 
blowpipe,  illustrated  in  Fig.  80,  may  be  advantage- 
ously used. 

Fig.  80. 


This  instrument  consists  of  a  small  blowpipe,  with 
a  cylinder  an  inch  long  and  half  an  inch  in  diameter ; 
this  is  placed  down  within  two  inches  of  the  point 
of  the  instrument.  This  cylinder  is  either  made  of 
very  heavy  metal,  or  filled  with  wire  or  something 
that  will  retain  heat ;  on  the  other  end  is  attached  a 


188  FILLING    TEETH. 

stiff  India-rubber  ball,  with  an  eyelet  opening,  one- 
fourth  inch  in  diameter.  By  placing  the  thumb  upon 
this  opening  and  making  compression,  a  jet  of  air  is 
forced  through  the  point  of  the  pipe,  and  the  cylinder 
being  previously  heated,  the  temperature  of  the  jet 
will  be  governed  by  that  of  the  cylinder,  and  the 
velocity  with  which  it  is  forced  through  the  instru- 
ment. This  jet  thrown  into  a  cavity  that  has  been 
made  as  diy  as  possible  by  wiping,  soon  makes  a 
very  perceptible  change,  the  walls  becoming  whiter 
than  before.  This  we  consider  the  most  desirable 
condition  in  respect  to  dryness  that  can  be  obtained. 

INTRODUCING    THE    FILLING. 

Having  in  all  these  steps  for  the  preparation  of 
the  cavity  made  thorough  work,  the  next  thing  to 
be  accomplished  is  the  introduction  and  consolidation 
of  the  filling.  The  manner  of  performing  this  part  of 
the  work  will  be  governed  by  the  kind  of  material 
employed,  and  also,  somewhat,  by  the  form  of  the 
particular  material,  as  well  as  the  method  adopted. 
Some  materials,  as  gold,  for  instance,  may  be  used  in 
six  to  eight  different  forms,  each  involving  a  prin- 
ciple peculiar  to  itself;  and  each  of  these  forms  is 
susceptible  of  being  used  in  different  ways.  It  is 
proposed   to  describe,  as   clearly  and   concisely  as 


INTRODUCTION    OF   THE   FILLING.  189 

possible,  the  A'^arious  methods  of  filling  that  have 
been  found  efficient.  This  is  the  more  important 
since  different  operators  differ  in  their  election  of 
methods ;  some  preferring  one,  others  another, — the 
result  of  mere  choice,  habit,  or  some  peculiar  fitness. 

The  first  method  for  consideration  is  that  of  filling 
with  ordinary  non-cohesive  gold  foil.  The  principles 
applicable  to  the  use  of  this  kind  of  foil  also  obtain  in 
the  use  of  foils  of  other  metals.  Gold  is  used  far  more 
than  anything  else.  The  common,  and,  indeed,  the 
almost  universal  method  of  using  foil,  in  the  early 
periods  of  the  profession,  was  in  the  form  of  a  roll, 
or  rope,  as  it  is  sometimes  called.  By  this  method 
the  foil  is  cut  into  strips  from  one-third  of  an  inch 
to  two  inches  w^ide,  the  width  being  governed  some- 
what by  the  size  of  the  cavity  to  be  filled.  This 
strip  is  then  rglled  lengthwise,  forming  a  loose  roll. 
The  compactness  of  the  roll  should  depend  upon  the 
thickness  of  the  foil,  and  the  size  of  the  points  with 
which  it  is  to  be  condensed ;  the  smaller  the  points, 
the  more  compact  the  roll  may  be. 

It  may  be  introduced  either  with  the  condensing 
instrument  or  with  the  plugging  pliers.  If  with  the 
former,  it  is  taken  up  at  ^  one  end  on  the  point 
of  the  instrument,  and  passed  to  the  bottom  of  the 
cavity;  and  that  portion  within  the  cavity  is  then 
pressed  firmly  against  the  wall  where  it  is  desirable 


190  FILLING    TEETH. 

to  begin  the  filling.  There  is  no  definite  uniform 
point  in  cavities  at  which  to  begin  the  introduction 
of  the  gold ;  usually,  however,  in  crown  cavities  of 
the  molars,  at  the  posterior  wall.  At  whatever  point 
the  filling  is  commenced,  the  cavity  should  be  so 
formed  that  it  will  retain  in  position  the  first  portion 
of  gold  introduced  ;  and  this  may  be  done  by  forming 
a  little  pit  or  groove  for  its  reception.  This  is  a  par- 
ticular that  cannot  with  impunity  be  neglected.  The 
gold  should  never  change  its  position  after  it  is 
pressed  to  the  wall  of  the  cavity ;  for  its  position 
cannot  be  changed,  except  at  a  sacrifice  of  the  adapta- 
tion, after  it  is  condensed.  The  end  of  the  roll  being 
placed  in  the  cavity,  it  is  seized  far  enough  without 
the  cavity  to  form  a  fold  that  will  extend  to  the 
bottom,  and  protrude  about  one  line  beyond  the 
border  of  the  orifice.  This  fold  is  pressed  firmly 
upon  the  preceding  portion  of  gold  and  adjacent 
walls.  Thus  fold  after  fold  is  introduced,  passed  to 
the  bottom  of  the  cavity,  and,  protruding  from  the 
orifice,  consolidated  firmly;  each  portion  as  it  is  in- 
troduced should  be  well  adapted  to  the  walls  of  the 
cavity  and  the  preceding  portion  of  the  filling. 

It  is  important  to  obtain  as  complete  an  adaptation 
of  the  filling  to  the  walls  of  the  cavity  as  possible ; 
and  in  order  to  accomplish  this,  the  centre  should  not 
be  filled  too  rapidly.     The  gold  is  thus  introduced 


INTRODUCTION    OF   THE    FILLING.  191 

fold  after  fold  till  the  cavity  is  full.  When  it  is  filled 
to  two-thirds  of  its  diameter,  the  gold  should  then  be 
adjusted  to  all  the  remaining  walls  of  the  cavity,  and 
the  last  portions  of  gold  introduced  somewhere  in 
the  body  of  the  filling,  certainly  not  next  to  any  wall 
of  the  cavity.  A  more  thorough  adaptation  of  the 
gold  can  be  made  to  the  walls  of  the  cavity  by  this 
manner  of  arranging  it  than  by  introducing  the  last 
portion  at  one  side  of  the  cavity.  There  is  less  lia- 
bility of  fracturing  a  frail  tooth  by  placing  the  gold 
on  the  walls  first,  and  terminating  the  introduction 
of  it  at  or  near  the  centre  of  the  filling.  It  is  the 
practice  with  some  to  introduce  the  gold  rather 
loosely,  or  without  much  condensing,  and  after  being 
introduced  in  this  manner,  to  condense  by  forcing 
into  it  a  wedge-shaped  instrument  at  various  points, 
and  filling  these  perforations  with  small  rolls  of  gold, 
continuing  to  use  the  wedge-shaped  instrument  as 
long  as  it  can  be  forced  into  the  filling.  This  method 
is  by  no  means  as  efficient  as  that  of  condensing  each 
portion  as  it  is  introduced.  By  the  latter  plan  the 
filling  can  be  made  uniformly  dense  from  the  surface 
to  the  bottom.  This  cannot  be  done  by  the  use  of  the 
w^edge-shaped  instrument;  it  will  compress  most  at  its 
largest  diameter,  that  is,  at  the  surface  of  the  filling. 
In  no  filling,  even  when  the  walls  of  the  cavity  are 
parallel,  will    a  uniform  density  throughout  be  ob- 


192  FILLING   TEETH. 

tained  by  perforating  with  the  wedge-shaped  instru- 
ment. The  filling  would  be  most  dense  at  the  sur- 
face, and  gradually  less  so  all  the  way  to  the  bottom. 
This  method  is  objectionable  for  condensing  the 
fillings  on  the  masticating  surfaces  of  the  molars ; 
for  in  the  act  of  mastication  the  inner  portion  would 
yield,  the  surface  of  the  filling  would  be  crowded 
down  into  the  cavity,  and  the  dentine  within  the 
orifice  become  exposed,  and  decay  be  the  result.  In 
proximal  fillings,  this  objection  would  not  have  the 
same  force.  In  pressing  an  instrument  of  a  wedge 
form  into  a  filling  with  sufficient  force  to  condense 
the  mass,  there  would  be  great  danger  of  breaking 
a  weak  wall  of  the  cavity.  The  principal  pressure 
is  lateral,  and  would  consequently  come  upon  the 
side  of  the  tooth. 

In  crown  cavities  of  the  molars,  where  there  is  any 
considerable  inward  expansion  of  the  cavity,  that 
method  of  condensing  would  be  wholly  inefficient ;  it 
would  not  render  the  inner  portion  dense  enough  to 
support  the  surfVice  of  the  plug,  and  it  would  be 
forced  down,  and  necessarily  be  loose.  In  filling  the 
proximal  cavities  of  the  incisors,  it  is  very  objection- 
able on  account  of  the  great  liability  of  breaking  the 
inner  and  outer  walls,  which  are  usually  quite  thin. 

In  preparing  the  foil  for  filling,  some  operators 
tear  off  the  foil  in  irregular  pieces,  and  form  these 


INTRODUCTION    OF   THE    FILLING.  193  . 

into  little  halls  or  pellets,  round  and  loosely  rolled, 
corresponding  in  size  with  the  cavity  to  be  filled. 
These  pellets  are  placed  in  the  bottom,  if  a  crown 
cavity,  and  at  one  side  if  a  proximal  cavity,  and  con- 
densed with  a  sharp-pointed  instrument,  attaching 
one  pellet  to  another  till  the  cavity  is  full.  This 
mode  is  not  so  good  as  that  previously  referred  to, 
unless  the  gold  is  in  a  condition  to  weld  perfectly ; 
there  is  no  continuous  portion  from  the  bottom  to  the 
orifice  of  the  cavity,  and  the  outer  portions  are  liable 
to  become  detached.  Both  of  these  methods  of 
arranging  the  gold  are  objectionable  in  one  par- 
ticular, namely,  the  irregularity  of  the  leaves  or 
laminae  of  the  foil;  these  are  placed  in  the  cavity 
without  regard  to  regularity,  and  the  consequence  is 
that,  without  great  care,  far  less  gold  will  be  intro- 
duced than  by  some  other  arrangement.  Much  more 
difficulty  is  experienced  in  obtaining  a  uniform  and 
equal  density  than  when  the  laminae  are  placed 
smoothly  together. 

Another  method  of  preparing  the  foil  is  to  fold  it 
into  from  four  to  twelve  thicknesses,  then  cut  off 
strips  in  width  corresponding  to  the  diameter  of  the 
cavity.  The  strip  thus  prepared  is  introduced  in  the 
same  manner  as  the  roll,  except  that  as  each  fold  is 
inserted,  it  is  placed  smoothly  against  the  preceding 
portion,  and  kept  smooth  and  free  from  wrinkles. 


194  FILLING    TEETH. 

By  this  arrangement  very  little  force  is  required  to 
bring  the  folds  in  perfect  contact.  Some  care  and 
skill  ^vill  be  necessary  to  bring  the  instrument  to 
bear  upon  the  whole  surface  of  the  fold.  More  gold 
can  be  put  into  a  cavity  in  this  manner  than  in  rolls 
or  pellets,  unless  these  are  used  in  small  portions, 
and  condensed  thoroughly  as  they  are  put  in. 


CYLINDER   OR   BLOCK    FILLING. 

Another  and  in  some  respects  f;xr  preferable 
method,  is  filling  Avith  cylinders  or  blocks.  Some 
of  the  advantages  of  this  method  over  that  just 
described  are  the  folloAving  :  the  filling  can  be  intro- 
duced far  more  rapidly ;  and  the  laminoe,  or  leaves  of 
foil,  take  a  more  perfect  position  in  the  cavity,  and 
consequently  the  structure  of  the  filling  is  better. 
The  form  of  the  cavity  should  be  much  the  same  as 
that  for  any  other  method  of  filling ;  there  should  be 
some  retaining  point  so  situated  that  the  first  block, 
or  blocks,  can  be  fixed  firmly  in  place,  so  that  there 
will  be  no  liability  of  loosening  during  the  subsequent 
part  of  the  process.  It  is  important  to  have  such  an 
arrangement,  as  otherwise  it  would  be  necessary  to 
employ  an  instrument  in  the  left  hand  to  retain  the 
first  blocks  in  situation,  till  enough  were  introduced 


CYLINDER    OR    BLOCK   FILLING.  195 

to  bind  the  "whole  by  pressure  upon  two  opposite 
points  in  the  cayity. 

Forming  Blocks. — For  forming  blocks,  use  any 
number  of  foil  that  may  be  desired,  usually  No.  4  or 
6,  and  either  lay  four  to  six  sheets  together,  or  fold 
a  single  sheet  into  that  number  of  thicknesses ;  then 
cut  off  from  the  sheets  thus  prepared  strips  about 
one-third  to  one-fourth  wider  than  the  depth  of  the 
cavity  to  be  filled ;  these  are  then  rolled  on  a  small 
three  or  four-sided  broach — the  three  sided  is  better. 
This  instrument  should  be  very  small — no  larger, 
indeed,  than  is  necessary  for  strength.  Its  sides 
should  be  perfectly  smooth,  and  its  angles  sharp ; 
ordinarily  it  should  not  taper,  or  at  least  but  slightly. 
For  forming  the  conical  blocks,  some  prefer  the 
tapered  broaches,  but  they  can  be  as  well  made  on 
the  parallel-sided  instruments.  The  strip  being  taken 
between  the  thumb  and  the  index  finger,  is  rolled  on 
the  broach  equally,  till  the  block  or  cylinder  is  large 
enough,  when  the  strip  is  broken  off.  The  size  of 
the  principal  part  of  the  blocks  should  be  determined 
by  the  size  of  the  cavity  to  be  filled.  Different  sizes 
and  forms  will  be  required  in  almost  every  case. 
Relatively  large  cylinders  may  be  employed  for  the 
principal  part  of  the  filling.  If  the  walls  of  the 
cavity  are  parallel,  almost  all  the  blocks  may  be 
cylindrical ;  but  if  there  is  an  under-dipping  of  one 


196  FILLING   TEETH. 

or  more  of  the  walls,  the  blocks  adjusted  to  that  par- 
ticular part  should  be  cone-shaped,  corresponding  to 
that  under-dipping.  A  number  of  small  graduated 
cone-shaped  blocks,  of  different  degrees  of  density, 
will  be  required  for  completing  each  filling;  as  the 
aperture  becomes  smaller,  smaller  blocks  will  be 
needed.  The  cone-shaped  blocks  are  formed  by  gra- 
dually running  the  strip  back  from  the  point  of  the 
instrument  as  it  is  wound  on ;  greater  or  smaller 
taper  can  be  given  to  it  as  the  strip  is  run  less  or 
more  rapidly  back  from  the  point.  The  density  of 
the  block  can  be  regulated  by  the  firmness  with 
which  the  strip  is  held  between  the  thumb  and 
finger,  upon  which  it  is  well  to  have  a  suitable  cover- 
ing, to  protect  the  gold  from  the  perspiration  of  the 
hand.  There  are  other  methods  of  forming  blocks. 
Cylinders  and  blocks  are  prepared  by  foil  manufac- 
turers, but  they  are  not  made  in  sufficient  variety, 
in  respect  to  form  and  density,  to  meet  all  cases ;  but 
they  should  always  be  at  hand,  and  any  deficiency 
may  be  supplemented  by  the  dentist.  They  may  be 
made  square,  by  making  a  great  number  of  folds — 
fifteen  to  thirty — and  from  this  cutting  strips  as 
before  directed,  and  then  from  these  heavy  strips 
cutting  off  the  blocks  of  the  desired  size,  which  will 
then  be  flat  or  nearly  square.  In  one  respect  these 
blocks  are  objectionable.    The  edges  when  they  have 


CYLINDER    OR    BLOCK   FILLING.  197 

been  cut  off  are  rendered  dense  by  the  action  of  the 
shears,  so  that  they  do  not  possess  the  uniform  den- 
sity or  consistence  of  the  rolled  blocks  or  cylinders, 
and  it  is  impossible  to  adapt  them  as  perfectly  to  the 
walls  of  the  cavity,  or  to  one  another.  This  objec- 
tion, however,  may  be  obviated  by  cutting  off  the 
blocks  with  a  very  fine  saw. 

Another  method  of  forming  blocks  is  to  roll  a  sheet 
of  No.  5  foil  into  a  rope,  and  cut  off  from  it  blocks 
corresponding  with  the  size  of  the  cavity  to  be  filled. 
These  are  liable  to  the  same  objection  as  those  last 
mentioned,  the  shears  hardening  them  when  they 
are  cut  off.  They  are  subject  to  the  additional 
objection,  that  the  folds  of  foil  are  not  as  regular 
as  by  either  of  the  other  methods.  But  by  proper 
manipulation,  with  the  gold  prepared  in  this  manner, 
superior  fillings  may  be  made.  Another  method  of 
preparing  blocks  is  by  cutting  a  sheet  of  foil  into  two 
or  three  pieces,  then  rolling  them  diagonally  on  a  steel 
wire  or  rod ;  the  size  of  this  wire  will  be  deter- 
mined by  the  required  length  of  the  blocks  ;  as  there 
should  be  blocks  of  different  lengths,  the  wires  should 
be  of  different  sizes,  and  range  from  No.  2  to  No.  12 
of  White's  bur  gauge  plate.  The  size  of  the  wire  will 
be  determined  by  the  depth  of  the  cavity.  The  wire 
being  withdrawn,  the  roll  is  compressed  to  a  strip. 
These  strips  are  now  rolled  squarely  upon  a  No.  20 


198  FILLING   TEETH. 

steel  wire,  the  size  of  the  cylinder  being  determined 
by  the  size  and  form  of  the  cavity  to  be  filled. 
These  may  be  used  either  in  their  cylindrical  form 
or  compressed  and  doubled.  The  cavity  formed  and 
the  blocks  prepared,  the  next  step  is  their  introduc- 
tion. 

Introducing  the  Blocks. — For  placing  the  gold  into 
the  cavity,  the  plugging  pliers  are  required,  the 
points  of  which  should  be  curved,  so  as  to  make  the 
most  direct  approach  to  the  cavity.  The  points,  too, 
if  properly  formed,  may  be  used  to  some  extent  for 
condensing  the  blocks.  All  things  being  ready,  the 
cavity  secured  against  the  encroachment  of  moisture 
from  the  saliva  and  breath,  the  left  hand  should  be 
employed  to  keep  the  rubber  and  the  soft  parts  of 
the  mouth  in  position.  If  there  is  an  angle,  a  small 
block  should  be  first  introduced  with  the  pliers  into 
the  proper  position,  one  end  upon  the  bottom  of  the 
cavity,  and  the  other  protruding  from  the  orifice,  and 
pressure  then  be  made  to  consolidate  it,  and  force  it 
into  its  position  against  the  wall  of  the  cavity.  This 
may  be  done  with  the  pliers,  or  better  with  the 
instrument  represented  by  Fig.  34.  The  part  of  the 
instrument  brought  to  bear  upon  the  gold  should  be 
roughened  either  longitudinally  or  transversely,  so 
that  a  proper  surface  may  be  left  for  the  reception  of 
the  succeeding  portions.    The  largest  blocks  are  then 


CYLINDER    OR   BLOCK    FILLING.  199 

introduced  and  consolidated  successively  as  described, 
the  end  of  each  left  protruding  till  the  cavity  is 
filled ;  each  portion  as  it  is  introduced  should  be  per- 
fectly condensed.  The  gold  should  be  filled  in  faster 
at  the  sides  of  the  cavity  than  in  the  centre,  thus 
being  disposed  round  the  walls  till  it  meets  at  a 
point  opposite  the  place  of  beginning;  and  thus  the 
gold  is  adapted  to  all  the  walls  of  the  cavity  before 
it  is  entirely  filled,  the  last  portions  being  introduced 
somewhere  near  the  centre  of  the  filling.  As  the 
cavity  diminishes  by  the  introduction  of  the  gold,  the 
small  and  more  dense  blocks  will  be  required ;  these 
should  be  forced  in  and  condensed,  by  crowding  the 
instrument  (Fig.  36)  down  against  the  side  of  the 
cone.  Some  operators  terminate  the  filling  against 
the  wall  of  the  cavity,  forcing  down  the  blocks  and 
compressing,  as  above,  till  it  is  full.  By  this  method 
there  is  danger  of  fracturing  the  tooth,  breaking 
down  the  wall  of  the  cavity,  where  the  filling  is  ter- 
minated. Another  method  is  to  fill  up  the  cavity 
principally  with  blocks,  and  to  put  in  the  last  part  of 
the  filling  in  the  strip,  filled  in  from  the  bottom  to 
the  orifice.  The  objection  to  this  method  is,  that 
unless  adhesive  foil  is  employed,  the  portion  inserted 
in  the  strip  is  liable  to  be  displaced,  and  in  this  way 
the  whole  filling  become  destroyed. 

Another  method  of  arranging  this  kind  of  filling, 


200  FILLING   TEETH. 

particularly  when  the  bottom  of  the  cavity  is  irreg- 
ular, is  to  make  a  large,  flat  pellet,  condense  it  firmly 
to  the  bottom,  and  set  the  blocks  upon  this  for  a 
foundation.  By  this  method  there  is  a  more  perfect 
adaptation  of  the  gold  to  the  bottom  of  the  cavity, 
than  by  placing  the  ends  of  the  blocks  down  upon  an 
uneven  surface.  After  the  gold  is  all  introduced,  a 
small-pointed  plugger  must  be  passed  over  the  entire 
surface,  to  consolidate  the  protruding  portions.  These 
protruding  portions  should  be  sufficient  to  make  the 
surface,  after  being  condensed,  perfectly  flush  with 
the  border  of  the  cavity,  for  a  depression  here  is 
fatal  to  a  complete  finish.  After  the  condensation 
with  the  finely-serrated  points  is  accomplished,  then 
the  blunt,  smooth,  polished  points  should  be  used 
with  the  mallet  all  over  the  surfiice  of  the  filling, 
then  the  files,  burs,  stones,  &c.,  of  the  various  grades 
should  be  used  to  complete  the  finish. 

Dr.  Badger  described  a  method  of  filling  a  small 
cavity  on  the  posterior  proximal  portion  of  a  second 
molar,  the  third  molar  gone.  The  cavity  is  formed 
with  a  bur  drill.  A  cylinder  is  then  formed  in  the 
usual  manner,  and  forced  through  a  series  of  holes  in 
a  drawplate,  down  to  the  size  of  the  bur  with  which 
the  cavity  is  prepared.  The  block  is  thus  rendered 
quite  dense.  The  cavity  is  then  dried,  and  the  block 
forced  into  it,  which  it  exactly  fits,  protruding  a  little 


COHESIVE    FOIL   FILLING.  201 

from  the  orifice.  This  block  is  pierced  in  the  centre 
with  a  sharp  instrument,  and  a  small  dense  roll 
forced  into  it ;  all  is  then  condensed,  and  finished  in 
the  usual  manner. 

Pellets. — Pellets  made  by  rolling  fragments  or 
pieces  of  foil  between  the  thumb  and  fingers  are  used 
by  some  operators,  and  with  them  they  profess  to 
make  as  good  filling  as  by  any  other  method.  They 
are  made  of  various  sizes,  and  packed  into  the  cavity 
with  sharp-pointed  or  serrate-pointed  instruments. 
The  pieces  may  thus  be  very  solidly  worked  to- 
gether, and  a  good  filling  made,  provided  the  pellets 
are  not  too  large ;  they  should  be  small  enough  to 
permit  the  point  or  points  to  work  through  them  into 
the  preceding  portions.  Some  operators  use  pellets 
and  crystal  gold  together.  This  may  do  very  well 
if  the  cohesive  property  of  the  gold  is  employed ; 
but  in  that  case,  either  form  of  the  material  would 
answer  alone.  There  cannot  be  as  much  gold  put  in 
by  pellets  as  by  blocks  or  cylinders  well  adjusted. 

Cohesive  Foil. — By  this  we  understand  that  condi- 
tion of  gold  foil  in  which  the  leaves  unite  readil}'' 
and  firmly  together.  This  property  of  cohesion  is 
possessed  in  the  greatest  degree  by  properly  manu- 
factured foil,  immediately  after  annealing.  Not  that 
annealing  imparts  any  new  property  to  the  gold,  but 
it  removes  obstacles   to  the   manifestion  of  a  prin- 


202  FILLING    TEETH. 

ciple  possessed  by  all  gold  under  favorable  circum- 
stances. It  is  now  about  twenty  years  since  this 
property  was  first  employed  in  gold  foil  for  filling 
teeth.  To  Dr.  R.  Arthur  is  due  the  credit  of  first 
directing  the  attention  of  the  profession  to  it,  as 
being  available  for  filling  teeth.  He  not  only  did 
this,  but  he  entered  most  fuUv  into  the  details  of  the 
manipulations,  instruments,  etc.,  pertaining  to  this 
mode  of  operation.  Almost  all  recently-prepared 
gold  foil  possesses  this  property  to  a  greater  or  less 
degree ;  there  are  methods  of  preparing  it,  however, 
by  which  it  possesses  it  most  fully ;  all  recently- 
annealed  foil  is  cohesive.  If  the  foil  is  in  this  con- 
dition when  we  wish  to  use  it,  nothing  further  is 
required  in  the  way  of  preparation.  But  if  it  is  not 
cohesive, — as  almost  all  foil  is  not,  especially  if  it  has 
been  much  exposed  to  the  influence  of  the  atmo- 
sphere,— it  will  require  to  be  made  so  by  some  pro- 
cess. There  are  two  methods,  either  of  which  will 
well  accomplish  the  object. 

The  one  most  frequently  employed  is  that  of  heat- 
ing the  gold,  either  in  the  sheet,  in  the  roll,  or  in 
fragments,  over  the  flame  of  a  spirit-lamp,  almost  or 
quite  to  a  read  heat ;  if  in  the  sheet,  it  should  be  laid 
upon  a  piece  of  wire  gauze,  and  passed  over  the 
flame  of  the  lamp  for  a  moment  or  two ;  if  in  the 
roll,  it  may  be  taken   in  the  centre  with  fine  pliers 


COHESIVE    FOIL   FILLING.  203 

and  passed  rapidly  through  the  flame.  But  if  the 
gold  is  in  the  form  of  pellets,  blocks,  cylinders,  or 
small  pieces  of  auy  shape,  it  may  be  taken  up  with 
the  pliers  and  passed  rapidly  through  the  flame  of  a 
spirit-lamp,  till  all  foreign  substance  is  burned  or 
driven  from  it.  Or  it  may  be  placed  on  a  sheet  of 
mica,  "which  is  adjusted  over  a  flame,  and  then 
brought  to  a  proper  temperature. 

There  are  different  methods  of  using  gold  in  this 
condition;  but  in  general  the  cavity  should  be  formed 
about  as  for  the  other  methods  of  filling,  except  that 
to  retain  the  first  piece,  there  should  be  two  or  three 
small  pits  or  holes  made  for  retaining-points  in  the 
most  available  position.  The  first  portion  of  gold 
should  be  a  little  pellet ;  this,  forced  into  these  re- 
taining-points, serves  as  a  foundation  for  the  remain- 
ing portion  of  the  filling.  Dr.  Arthur's  method  is, 
then,  to  tear  off  fragments  from  the  sheet,  and  pass  it 
into  the  cavity  without  folding  up,  and  condense  it 
with  an  instrument  of  finely  serrated  point,  so  that  it 
not  only  unites  by  cohesion,  but  is  worked  into  the 
surfiice  of  the  preceding  portion  of  gold ;  and  in  this 
manner  portion  after  portion  is  introduced  and  con- 
densed, until  the  cavity  is  full.  The  filling  may  be 
commenced  in  any  part  of  the  cavity  that  is  most 
convenient ;  in  many,  as  in  crown  cavities  of  the 
molars,  at  the  bottom,  and  filled  to  the  orifice.     In 


204  FILLING    TEETH. 

putting  in  the  gold,  it  should,  during  its  introduction, 
be  kept  fuller  about  the  walls  of  the  cavity  than  in 
the  centre ;  by  this  means  the  adaptation  will  be  most 
perfect  to  the  walls,  and  there  will  be  no  liability  of 
clogging  in  the  centre.  The  gold  may  thus  be  built 
up  to  any  desired  extent  if  the  filling  is  kept  dry ; 
moisture  is  fatal  to  its  cohesion. 

Others  use  the  cohesive  gold  in  a  different  man- 
ner. To  Dr.  Blakesley  belongs  the  honor  of  first  de- 
tailing the  following  plan  :  The  sheet  of  gold  may  be 
folded  or  not  at  the  pleasure  of  the  operator,  and  then 
each  sheet  cut  into  from  two  to  six  strips,  and  each 
of  these  formed  into  a  loose  roll  between  the  thumb 
and  fingers.  These  should  now  be  passed  through 
the  flame,  as  already  described,  then  cut  into  little 
blocks  or  pellets  of  various  sizes ;  these  to  be  regu- 
lated by  the  size  of  the  roll  and  the  cavity  to  be 
filled.  For  the  introduction  of  the  gold  thus  pre- 
pared, about  three  sizes  of  instruments  are  required, 
those  having  finely  serrated  points  being  preferable. 
As  to  the  sizes  of  these  points.  Dr.  Blakesley  re- 
marks, "  They  should  just  enter  respectively  Nos. 
22,  24,  and  16  of  the  wire-gauge."  A  larger  than 
either  of  these,  however,  is  desirable  for  many  cases. 
As  before,  the  filling  may  be  commenced  at  the  bot- 
tom of  a  cavity,  or  at  one  side,  if  desirable,  with  a 
pellet  sufficiently  large  to  be  set  firmly  into  the  re- 


THE    MALLET.  205 

taining  pits.  Then  take  up  the  *small  pellets  or 
blocks  upon  the  point  of  the  plugging  instrument, 
and  place  them  exactly  in  the  desired  position,  and 
consolidate  them  thoroughly,  building  up  next  to  the 
wall  all  around  higher  than  the  centre,  with  the 
smaller  pieces,  filling  up  the  little  corners  and  inter- 
stices, for  which  manipulation  the  smaller  points  will 
be  required.  The  gold  is  then  packed  in  till  the 
cavity  is  full,  when  it  is  finished  as  usual.  Another 
method  is  to  tear  off  fragments  from  the  sheet,  and 
roll  these  up  into  round  pellets,  and  fill  with  these, 
with  the  same  instruments  and  upon  the  same  prin- 
ciple as  above  described.  But  by  this  method  it  is 
difficult  to  make  a  perfect  filling ;  the  gold  is  liable 
to  clog  in  the  cavity,  and  fail  in  adaptation. 

Cohesive  gold  must  be  consolidated  as  it  is  intro- 
duced ;  for  if  a  cavity  is  full,  it  is  very  difficult  then 
to  condense  it  more,  even  though  the  consolidation  is 
but  partial ;  and  the  same  is  true  to  some  extent  of 
non-cohesive  foil. 

THE   MALLET. 

In  the  year  1860,  Dr.  W.  II.  Atkinson  intro- 
duced to  the  dental  profession  the  mallet  for  the 
purpose  of  condensing  gold  in  filling  teeth.  This 
effected  quite  a  change  in  the  theory  and  practice  of 


206 


FILLING   TEETH. 


this  i^art  of  the  work.  Prior  to  this  period  it  was 
accomplished  entirely  by  the  pressure  or  force  exerted 
by  the  hand.  There  was  very  considerable  diversity 
of  opinion  as  to  the  best  mode  of  this  manipulation, 
some  maintaining  that  great  force  is  always  required 
to  make  a  filling  sufficiently  dense, — assuming  that 
it  is  better  to  use  comparatively  large  points,  great 
pressure  and  rapid  execution,  thus  securing  the 
utmost  economy  of  time,  both  to  the  operator  and 
patient.  Others  entertain  the  opinion  that  with 
smaller  points,  less  pressure,  and  greater  time,  a 
more  definite  and  satisfactory  result  is  attained. 

Notwithstanding  the  diversity  of  opinion  and  prac- 
tice upon  this  subject,  Ave  would  suggest  that  young 
operators,  at  least,  should  bear  in  mind  that  in  so 
important  a  matter  as  filling  teeth,  efficiency  should 
never  be  sacrificed  to  rapidity. 

This  method  is  especially  applicable  and  effective 
for  the  condensation  of  cohesive  gold,  and  indeed 
gold  in  any  form,  when  the  aim  is  to  condense  each 
portion  as  it  is  introduced.  A  more  thorough  con- 
densation is  made  by  the  use  of  the  mallet  than  is 
possible  by  the  hand  alone ;  greater  precision  of 
manipulation  is  attainable  ;  it  is  easier  for  the  ope- 
rator, and  usually  less  unpleasant  to  the  patient. 

The  character  of  the  results  in  the  use  of  this 
instrument   depends    much   upon    the    skill    of   the 


THE    MALLET.  207 

assistant.  It  requires  time,  care  and  patience  to 
familiarize  an  assistant  with  the  use  of  the  mal- 
let. The  plugger  should  be  held  firmly  in  position 
by  th*  operator,  and  receive  the  stroke  squarely 
upon  the  end  ;  it  should  be  a  sharp,  springing  tap. 
Very  much  depends  upon  the  character  of  the  blow; 
a  dead,  heavy  stroke  will  not  unite  the  gold  as  it 
should  be.  It  is  important  that  the  assistant  be  able 
to  follow  the  indications  of  the  operator  without  loss 
of  time.  Many  assistants  are  disposed  to  give  time 
strokes  instead  of  following  indications,  which  are 
not  admissible  except  in  very  simple  cases. 

In  order  to  avoid  the  employment  of  an  assistant, 
and  to  place  the  strokes  of  the  instrument  more  under 
the  control  of  the  operator,  various  forms  of  auto- 
matic mallet  pluggers  have  been  invented  and  con- 
structed. Two  or  three  principles  embrace  the  whole, 
though  many  different  forms  have  been  made.  Those 
operated  by  the  action  of  spiral  springs  have  been 
the  more  common ;   the  objection   to   almost  all  of 

Fi::.  81. 


these  is.  that  the  stroke  lacks  the  desired  elasticity. 
This  class  of  instruments  is  represented  in  general 
aspect  by  Fig.  81. 


208 


FILLING    TEETH. 


Fie  82. 


This  instrument  was  invented  by  Dr.  I.  A.  Sal- 
mon, and  is  one  of  the  best  of  this  form ;  it  operates 
well  in  the  hands  of  those  who  become  familiar 
with  it. 

Another  form  of  mallet  plugger  is  represented  in 
Fig.  82,  in  which  the  blow  is  communicated  by  a 

spring  of  another  form, 
and    of     such    an    ar- 
rangement   as    to   give 
an  elastic  stroke.     This 
instrument  was  invented 
and  made  by  Dr.  W.  G. 
Redman.     It  would  be 
objectionable  in  the  hands  of  some,  because 
of  its  size,   weight   and   form.     Use    and 
custom  will   remove    great  apparent,   and 
even  real,  difficulties. 

Both  of  these  instruments  are  less  under 
the  control  of  the  operator,  in  respect  to 
the  force  of  the  blow,  than  they  should  be. 
It  is  true  that  in  both  the  force  can  be 
regulated  to  the  most  minute  degree,  be- 
tween a  very  light  and  a  very  strong  stroke ; 
it  cannot  be  done,  however,  without  giving 
special  attention  to  that  particular,  which 
necessitates  an  arrest  of  the  operation  of 
the  instrument. 


THE    MALLET.  209 

An  instrument  is  made  by  Dr.  S.  B.  Palmer,  in 
which  the  force  of  the  blow  is  placed  completely  under 
the  control  of  the  operator  while  it  is  being  used. 
The  operation  of  this  instrument  is  perhaps  less 
objectionable,  in  respect  to  the  character  of  the 
stroke,  and  its  control  by  the  operator,  than  any 
other  as  yet  employed.  Any  of  these  instruments 
are  valuable  in  the  hands  of  those  who  become 
familiar  with  them. 

During  the  last  few  years  efforts  have  been 
made  to  operate  the  mallet  by  various  motors.  The 
first  attempt  in  this  direction  was  by  Dr.  G.  W. 
Bonwell,  by  the  application  of  galvano-electricity. 
The  first  machines  were  very  crude  and  unsatisfac- 
tory ;  but  by  improvements  made  from  time  to  time, 
the  instrument  is  quite  efficient  in  the  hands  of  those 
familiar  with  it. 

A  mallet  has  been  invented  and  constructed  by 
Professor  T.  L.  Buckingham,  designed  to  be  attached 
to  and  operated  by  the  dental  engine.  It  is  more 
under  the  immediate  control  of  the  operator  than 
most  of  the  automatic  mallets  in  use.  This  is  highly 
prized  by  many.  The  pneumatic  mallet  was  devised 
by  Dr.  W.  11.  Jackson.  This  consists  of  an  ingenious 
and  yet  simple  application  of  air  as  a  motor.  For  a 
description  of  each  of  these,  with  illustrations,  see 
Appendix  of  this  work.  Sec.  C. 


210  FILLING   TEETH. 

CRYSTAL   OR    SPONGE    GOLD. 

The  form  of  the  cavity  for  crystal  gold  filling 
should  be  much  the  same  as  that  described  for  other 
fillings,  except  that  the  same  care  is  not  necessary 
for  special  retaining-points  ;  for  the  first  portion  of 
good  crystal  gold  that  is  introduced  into  the  cavity 
will  attach  to  the  walls  without  any  such  provision. 
Such  a  form  should  be  given,  however,  as  to  secure 
the  first  piece  firmly  in  place.  The  gold  should  be 
cut  or  broken  into  pieces  corresponding  in  size  to  the 
cavity,  so  that  they  will  enter  freely  into  it. 

The  filling  may  be  commenced  upon  the  bottom  of 
the  cavity,  or  upon  one  of  its  sides ;  such  a  point 
always  being  selected  as  will  most  effectually  retain 
the  gold  in  place.  The  pluggers  should  be  of  vari- 
ous sizes — the  first  one  as  large  as  can  be  used  freely 
in  the  cavity,  and  smaller  ones  for  condensing  more 
thoroughly ;  and  all  should  be  serrated.  The  blocks 
may  be  taken  up  on  the  point  of  the  plugger,  or 
perhaps  better  with  the  pliers,  and  passed  to  the 
proper  position  in  the  cavity,  and  there  condensed. 
The  sharp  serrated  point  leaves  the  surface  in  good 
condition  for  the  reception  of  the  next  piece.  The 
gold  should  be  packed  to  the  walls  of  the  cavity  a 
little  in  advance  of  the  centre,  so  that  its  adaptation 
may  be  more  complete.    In  this  manner  the  fiUins;  is 


CRYSTAL  OR  SPONGE  GOLD.  211 

built  up  as  much  as  is  desirable,  if  it  is  kept  dry, — 
and  unless  it  is,  cohesion  is  very  much  diminished, 
or  lost  altogether. 

The  gold,  after  it  is  cut  up,  is  passed  through  the 
flame  of  a  spirit  lamp,  to  anneal  it,  and  dispel  all 
foreign  substances.  It  should  in  no  case  be  brought 
above  a  perceptible  red  heat,  and  usually  not  to  that 
point ;  it  should  be  done  carefully,  so  as  not  to  fuse 
any  of  the  particles,  as  that  would  impair  their 
facility  of  cohesion  in  this  process.  Small  portions 
are  often  required  to  fill  up  small  interstices,  or 
notches. 

In  crown  cavities,  the  filling  should  begin  at  the 
bottom  ;  in  proximal  cavities,  at  the  cervical  wall. 
By  introducing  the  gold  in  this  manner,  the  pressure 
is  made  on-  a  line  with  the  axis  of  the  tooth,  which  is 
an  important  consideration.  The  surface  of  the  filling 
should  be  made  to  conform  to  that  of  the  lost  portion 
of  the  tooth ;  this  can  always  be  done  except  where 
the  tooth  is  largely  broken  away,  and  even  then 
very  much  may  be  accomplished  in  many  cases  to 
restore  the  lost  form;  that  will  depend,  however, 
upon  the  method  of  using  the  gold,  and  the  security 
of  the  attachment  for  it.  In  crown  fillings  of  the 
molars  and  bicuspids,  the  antagonism  of  the  teeth 
must  be  regarded ;  they  should  be  formed  for  the 
reception  of  the  cusps  of  the  opposing  tooth.    Proxi- 


212  FILLING   TEETH. 

mal  fillings  should  usually  be  convex ;  yet  many 
good  fillings  of  this  class  are  made  with  a  surface 
perfectly  plain  with  the  borders  of  the  cavity.  The 
borders  of  the  filling,  however,  are  better  protected 
when  it  is  somewhat  convex. 

Crystal  gold,  of  perfect  character,  presents  to  the 
walls  of  the  cavity  a  surface  better  calculated  to  be 
•retained  than  foil  in  any  of  its  forms  ;  though  cohe- 
sive foil  possesses  this  advantage  to  a  greater  extent 
than  foil  in  any  other  condition.  The  points  and 
edges  of  the  crystals  are  brought  in  contact  with  the 
walls,  and  take  a  firmer  hold  upon  the  dentine. 

In  forming  crystal  gold  into  a  solid  mass,  two 
principles  are  operative  :  cohesion  acts  upon  it  as 
potentially  as  upon  gold  in  any  other  form,  and,  in 
addition,  there  is  the  interlacing,  or  locking,  of  the 
crystals  with  one  another;  so  that  a  more  perfect 
union  of  the  different  portions  of  which  a  filling  is 
composed  is  obtained  with  crystal  gold  than  with 
foil.  Yet  good  cohesive  foil,  when  properly  manipu- 
lated, attains  almost  the  same  condition. 

It  is  important  to  keep  the  gold  perfectly  free  from 
moisture  while  being  introduced  and  consolidated ; 
for  moisture  instantly  destroys  its  cohesive  property. 
And  the  more  complete  the  exclusion  of  moisture 
from  the  cavity  during  the  process,  the  better  for 
the  success  of  the  operation.     The  surface  of  every 


CRYSTAL    OR    SPONGE    GOLD. 


213 


filling  should  be  consolidated  for  finishing  before 
it  is  allowed  to  become  moist,  for  if  it  becomes 
saturated  with  moisture  before  consolidation,  it  is 
impossible  to  make  a  perfect  finish.  There  should 
always  be  gold  enough  superadded  to  insure  this  ; 
and  the  consolidation  of  the  surface  should  be  effected 
with  a  burnisher  of  the  proper  form,  used  with  the 
mallet,  consolidating  the  entire  surface  as  thoroughly 

Fig.  83. 


k  ^ 


and  smoothly  as  possible,  exercising  great  care  about 
the  borders  of  the  filling.  Fig.  83  represents  the 
forms  of  the  burnishers  suitable  for  almost  all  cases. 


FINISHING    FILLINGS. 


The  method  of  finishing  a  filling,  and  the  manipu- 
lation required,  will  depend  somewhat  on  its  locality. 
When  the  filling  has  been  thoroughly  consolidated 


214  FILLING    TEETH. 

over  all  the  surface,  and  especially  all  round  its 
border,  the  file  should  be  applied  to  dress  off  any 
projecting  portion,  and  render  it  smooth.  In  con- 
solidating the  surface,  an  instrument  should  be  used 
that  would  not  pit  it,  and  the  file  or  finishing  bur 
should  remove  all  indentations.  The  work  of  these, 
however,  should  be  but  partially  performed  at  first, 
and  the  surface  burnished  again.  To  obtain  the  most 
perfect  finish,  the  surface  should  be  brought  to  a 
uniform  consistence;  and  this  condition  cannot  be 
reached  by  the  use  of  sharp-pointed  instruments,  nor 
fully  by  that  of  the  blunt  plugger  at  the  first  effort, 
but  by  the  alternate  use  of  the  file,  the  blunt  con- 
denser, with  the  mallet,  and  the  burnisher.  A  coarse 
file  or  bur  should  be  employed  in  this  part  of  the 
process ;  but  when  the  filling  is  dressed  sufficiently, 
and  in  good  condition,  the  fine  file  should  be  used 
alternately  with  the  burnisher,  till  a  perfectly  uni- 
form surface  is  obtained.  In  all  cases,  after  the  file 
has  been  applied,  the  plug  should  be  washed  off  with 
a  brush,  to  remove  all  detached  pieces  of  gold,  before 
the  burnisher  is  put  upon  it ;  and  after  the  fine  file 
and  burnisher,  the  Scotch  or  Arkansas-stone,  or 
corundum  slips  of  the  proper  form,  used  with  the 
port-polisher,  or  very  fine  pumice,  should  be  employed 
to  remove  the  file-marks.  The  pumice  may  be  applied 
with  water  on  a  strip  of  chamois  skin,  a  piece  of 


FINISHING   FILLINGS.  215 

linen  tape,  or  a  stick  of  soft  wood — the  latter  being 
the  most  convenient,  as  it  can  be  used  with  one 
hand — shaped  to  suit  any  place  or  position.  Emery 
cloth  of  every  requisite  grade  of  fineness  is  now  ob- 
tainable ;  this  may  be  cut  into  strips  of  any  desired 
width.  It  is  very  efficient  for  finishing  all  fillings  in 
the  proximate  portions  of  the  teeth. 

After  the  stone  or  the  pumice  has  accomplished  its 
work,  and  the  filling  has  been  thoroughly  washed,  a 
fine  burnisher,  with  a  solution  of  castile  soap,  is  em- 
ployed to  give  the  finish.  The  burnisher  should  be 
of  the  best  cast  steel,  and  of  high  temper  and  fine 
polish.  Considerable  skill  is  requisite  to  give  the  best 
effect  with  the  burnisher ;  it  should  pass  smoothly 
and  gently  over  the  surface,  throughout  its  whole 
extent,  and  in  parallel  lines,  with  a  pressure  neither 
too  light  nor  too  heavy.  It  should  also  be  applied 
very  thoroughly  upon  any  portion  of  the  tooth  about 
the  border  of  the  filling  that  may  have  been  cut  by 
the  file  or  any  other  instrument.  Indeed,  quite  as 
much,  if  not  more,  care  should  be  exercised  upon 
this  as  upon  the  plug  itself:  it  should  be  polished  as 
smooth  as  the  enamel,  if  possible,  for  the  more  nearly 
perfect  it  is  in  this  respect,  the  better  Avill  it  resist 
the  action  of  the  deleterious  agents. 

This  method  of  finishing  gives  to  the  filling  a  per- 
fect metallic  lustre,  which,  under  some  circumstances, 


216  FILLING    TEETH. 

is  objectionable.  Two  other  methods  are  in  use  : 
After  the  burnisher  has  been  applied,  as  above,  the 
buff  or  tape,  with  rouge,  may  be  employed,  by  passing 
it  rapidly  over  the  filling,  till  the  metallic  lustre  is 
destroyed,  or  deadened,  so  as  not  to  reflect  the  light 
as  before,  thus  leaving  a  very  desirable  finish ;  and 
the  other  method  is,  to  stipple  over  the  surface  of 
the  burnished  filling  with  the  end  of  a  piece  of  hard 
wood, — sandal  wood  is  recommended, — charged  with 
finely-pulverized  pumice.  This  gives  a  beautiful, 
velvet-like  surface,  and  is  applicable  to  fillings  in  the 
anterior  portion  of  the  mouth,  where  they  are  ex- 
posed to  view.  Rotten-stone,  applied  either  with 
the  buff  or  with  hard  wood,  imparts  a  finish  which, 
although  a  little  different,  is  equal  to  any  of  the 
others. 

For  finishing,  some  operators  prefer  to  cut  and 
polish,  instead  of  filing  and  burnishing.  But  neither 
so  good  nor  so  fine  a  finish  can  be  effected  in  this 
way,  and  it  is  probable  that  economy  of  time  and 
labor,  especially  the  latter,  suggested  the  method. 
The  introduction  and  use  of  the  corundum  cones  and 
disks,  cones  of  Hindustan  and  Scotch  stone,  and  the 
wood  cones  and  buffs  (represented  on  pp.  115,  110), 
all  to  be  used  with  the  dental  engine,  greatly  facili- 
tate the  work  of  finishing,  and  perhaps  accomplish  it 
better ;  but  great  care  should  always  be  exercised  in 


I 


FINISHING   FILLINGS.  217 

the  use  of  these  implements.  In  all  cases  the  filling 
should'  have  a  distinct  and  definite  margin ;  the  gold 
should  be  trimmed  off  quite  up  to  the  border  of  the 
cavity,  by  passing  round  it  a  small  sharp  instrument, 
so  as  to  detect  and  pare  down  any  portion  that  might 
overlap  the  tooth ;  for  if  overlapping  portions  are 
permitted  to  remain,  foreign  substances  will  lodge 
beneath,  and  induce  decay.  Neglect  in  this  particu- 
lar has  occasioned  the  loss  of  thousands  of  teeth  that 
otherwise  might  have  been  saved.  This  direction 
does  not  apply  to  those  cases  elsewhere  mentioned, 
in  which  it  is  recommended  to  form  a  thick,  firm, 
overlapping  portion,  for  the  protection  of  a  thin 
friable  border. 

The  subject  of  finishing  is  almost  entirely  over- 
looked by  very  many  operators,  but  by  the  neat  and 
skillful  it  is  esteemed  of  sufficient  importance  to  de- 
mand as  great  labor  and  pains  as  any  other  part  of 
the  work. 


CHAPTER  VII. 

CLASSIFICATION    OF    DECAYED    CAVITIES. 

The  following  classification  of  decayed  cavities  in 
the  teeth,  though  from  the  very  nature  of  the  subject 
imperfect,  will  be  found  sufficiently  accurate  to  aid 
the  dental  student  and  the  practitioner.  It  is  based 
primarily  on  the  position  of  the  cavities,  and  second- 
arily on  the  extent  of  the  decay, — the  classes  having 
reference  to  the  former  and  the  modifications  to  the 
latter.  The  classes  are  numbered  according  to  the 
accessibility  of  the  cavities,  beginning  with  those 
most  easily  approached  and  operated  upon,  and  the 
modifications  according  to  the  extent  of  the  decay, 
beginning  with  the  smallest  and  simplest  in  form. 

First  Class. — Simple  central  crown  cavities  in  the 
molars  and  bicuspids. 

\st  Mod. — Extension  of  the  decay  along  one  or 
more  fissures  or  depressions. 

"Id  Mod. — Two  decays  in  close  proximity  on  the 
same  crown,  which  may  be  formed  into  one  cavity 
for  filling. 

Second  Class. — Cavities  in  the  buccal  and  palatal 


CLASSIFICATION    OF    DECAYED    CAVITIES.  219 

surfaces  of  the  molars  and  bicuspids,  and  in  the  labial 
and  palatal  surfaces  of  the  canines  and  incisors. 

1st  3Iod. — Extension  of  the  decay  beneath  the 
margin  of  the  gums. 

2d  3Iod. — Extension  of  the  decay  so  as  to  involve 
a  portion  of  the  crown  surface. 

Third  Class. — Anterior  proximal  cavities  of  the 
bicuspids  and  molars. 

1st  3fod. — Extension  of  the  decay  toward  the  neck 
of  the  tooth,  beyond  the  termination  of  the  enamel. 

2d  Mod. — Extension  of  the  decay  so  as  to  involve 
a  portion  of  the  grinding  or  crown  surface. 

Fourth  Class. — Proximal  cavities  of  the  incisors 
and  canines. 

1st  3Iod. — Palatal  wall  of  the  cavity  broken  away. 

2d  3Iod. — Labial  wall  broken  away. 

€id  3fod. — The  cavity  at  the  point  of  the  tooth, 
terminating  at  the  surface. 

ith  3Iod. — The  borders  of  the  cavity  very  thin, 
and  the  lateral  walls  inclining  to  the  centre. 

Fifth  Class. — Posterior  proximal  cavities  of  the 
molars  and  bicuspids. 

Modifications  same  as  those  of  third  class. 

Modifications  common  to  all  the  classes: — 1st.  Su- 
perficial cavity  and  a  large  orifice.  2d.  Deep  cavity 
and  a  small  orifice. 

Modification   common  to '  classes   three,  four,  and 


220  CLASSIFICATION    OF    DECAYED    CAVITIES, 


five: — Transverse  extension  of  the  decay  round  one 
or  more  ang 
the  enamel. 


or  more  angles  of  the  tooth,  under  the  termination  of 


FILLING    BY    CLASSES    AND   MODIFICATIONS. 

First  Class. — Central  cavities  of  the  molars  and 
bicuspids.  These  decays  always  begin  in  the  depres- 
sions on  the  masticatory  surfaces,  which  are  vulner- 
able points,  the  enamel-membrane  folding  together 
here,  and  often  being  imperfectly  united,  so  that  an 
opening  is  left  partially  or  wholy  through  it  to  the 
dentine ;  besides,  these  indentations  afford  lodgment 
to  foreign  substances,  which  may  be  forced  into  them 
in  the  process  of  mastication,  and  there  retained  till, 
becoming  vitiated,  they  produce  decay. 

Examine  carefully  the  extent  and  the  nature  of 
the  decay,  and  the  form  of  the  cavity,  which,  of 
course,  greatly  varies.  In  some  cases  the  cavity  is 
found  with  a  small  diameter  and  a  comparatively 
great  depth,  the  diameter  at  the  orifice  being  the 
same  as  within;  in  others,  with  a  diameter  larger 
at  the  orifice,  as  occurs  in  cases  in  which  a  consider- 
able portion  of  the  enamel  at  the  depressions  on  the 
crown  is  imperfect.  In  the  majority  of  instances, 
however,  the  diameter  of  the  cavity  is  much  larger 
within  than  at  the  orifice.     Sometimes  the  decay  is 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  221 

found  to  burrow  directly  beneath  the  enamel  more 
rapidly  than  in  any  other  direction,  as  where  there  is 
an  imperfect  union  between  the  enamel  and  the  den- 
tine. In  other  instances,  the  cavity  seems  to  expand 
jmiformly  as  it  extends  into  the  tooth. 

The  manner  of  opening  up  and  preparing  the 
cavity  for  filling  will  depend  somewhat  on  the  form 
given  to  it  by  the  decay.  If  it  is  larger  at  the  orifice 
than  within,  there  will  be  little  or  no  cutting  of  the 
cavity  about  the  orifice  necessary,  except  to  make  it 
even  and  smooth ;  and  its  preparation  will  consist  in 
an  entire  removal  of  the  decay,  and  such  shaping 
of  the  interior  as  will  insure  retention  of  the  filling. 
This  may  be  effected  either  by  enlarging  the  cavity 
within,  till  its  walls  are  parallel  with  each  other,  or, 
if  these  are  left  converging,  by  forming  pits  or  grooves 
upon  them  at  proper  points.  Converging  walls  pre- 
sent one  or  two  advantages,  Avhich  will  be  hereafter 
considered.  Usually,  where  the  decay  has  formed  a 
cavity  of  nearly  uniform  diameter  from  the  orifice  to 
the  bottom,  about  all  the  preparation  for  filling  that 
is  requisite  is  a  thorough  removal  of  the  decay.  In 
cases  in  which  the  decay  burrows  under  the  enamel, 
the  projecting  portions  are  to  be  cut  down,  either  with 
a  bur  drill  or,  what  is  generally  better,  a  heavy 
cutting  instrument.  In  most  instances  it  is  best  to 
cut  away  the  enamel  as  far  as  the  decay  has  extended 


222  CLASSIFICATION    OF    DECAYED    CAVITIES. 

beneath  it,  since  it  is  difficult  to  make  a  perfect  fill- 
ing under  a  projecting  portion.  In  some  cases,  how- 
ever, where  the  enamel  is  thick  and  firm,  it  is  admis- 
sible to  leave  a  slight  projection,  so  as  to  form  a 
shallow  groove. 

The  walls  of  these  cavities  will  be  of  various  in- 
clinations. If  they  converge,  pits  or  grooves  may  be 
required  upon  them  for  retaining-points,  especially  if 
the  enamel  is  cut  away  at  the  orifice  to  the  solid 
dentine.  If,  however,  the  walls,  or  two  opposite 
walls,  are  parallel,  or  but  slightly  divergent,  these 
special  retaining-points  will  not  be  requisite,  except 
for  the  reception  of  the  first  pieces  of  gold.  Small 
cavities  of  this  class  may  be  opened  up  and  formed 
principally  with  the  bur  and  drill ;  and  even  in  large 
cavities  much  of  the  work  of  opening,  excavating, 
and  forming  may  be  done  with  burs  of  the  proper 
size  and  form,  used  with  the  engine.  Thus  the 
orifices  of  the  small  cavities  would  be  round,  while 
those  of  the  large  would  be  of  various  forms,  deter- 
mined by  the  direction  of  the  decay,  as,  round, 
square,  triangular,  elliptical,  parallelogramic.  Cavi- 
ties should  not  be  formed  much  larger  within  than  at 
their  orifices,  unless  the.  filling  can  be  consolidated  so 
perfectly  that  it  will  not  yield  in  the  least  under  the 
greatest  pressure  of  mastication ;  for,  if  there  is 
yielding  in  such  cases  under  direct  pressure,  the  fill- 


FILLING   BY   CLASSES    AND    MODIFICATIONS.  223 

ing  being  forced  into  a  larger  part  of  the  cavity,  with- 
draws from  the  walls,  leaving  an  interval  correspond- 
ing with  the  depression  it  has  undergone ;  and  thus 
fluids  would  be  admitted  between  the  walls  and  the 
filling,  and  the  purpose  for  which  this  was  inserted 
would  be  entirely  defeated. 

Many  operators  ream  the  orifices  of  all  the  small 
and  medium-sized  cavities  of  this  class,  in  order 
thereby  to  make  a  better  finish  to  the  border  of  the 
filling.  Some  operators  prefer  in  all  cases  to  remove 
the  angle  formed  by  the  wall  of  the  cavity  and  the 
surface  of  the  tooth  about  the  orifice,  giving  a  rounded 
form  to  the  border  of  the  orifice,  the  object  being  to 
avoid  fracturing  or  comminuting  the  edge  of  the 
enamel  or  dentine  about  the  cavity.  All  acute  angles 
in  these  cavities,  especially  if  they  extend  to  the 
orifice,  should  be  obliterated,  since  it  is  impossible  to 
fill  them  perfectly.  This  obliteration  can  be  effected 
with  a  miniature  chisel,  or  with  the  appropriate  exca- 
vator, or,  perhaps  better  still,  with  the  bur  of  the 
proper  size  and  shape. 

After  the  formation- of  the  cavity,  the  next  particu- 
lar is  so  to  arrange  as  entirely  to  exclude  moisture, 
whether  from  the  saliva  or  from  the  breath.  If  pro- 
vision was  not  made  at  the  beginning  of  the  opera- 
tion for  the  exclusion  of  moisture,  it  cannot  now  be 
longer  delayed.    As  already  intimated  elsewhere,  this 


224  CLASSIFICATION    OF    DECAYED    CAVITIES. 

is  accomplished  by  the  use  of  the  rubber  dam.  The 
general  method  of  its  application  has  been  considered, 
yet  a  few  suggestions  in  reference  to  it  in  an  opera- 
tion upon  this  class  of  cavities  may  be  of  value, 
especially  to  the  beginner. 

The  precise  method  of  procedure  at  this  point  will 
be  modified  by  the  size  of  the  mouth,  and  the  ability 
or  will  of  the  patient  to  control  it.  For  a  cavity  of 
this  class,  it  will,  in  nearly  all  cases,  where  the 
mouth  is  fav^orable  in  the  particulars  just  referred  to, 
be  quite  sufficient  to  embrace  with  the  rubber  only 
the  tooth  to  be  operated  upon,  and  this  whether  it  be 
in  the  superior  or  inferior  jaw. 

If  the  tooth  in  question  stands  in  firm  contact  with 
its  neighbors,  passing  the  rubber  between  the  teeth 
may  be  quite  unnecessary,  but  let  it  be  drawn  over  the 
crown,  and  down  or  up,  as  the  case  may  be,  upon  the 
buccal  and  lingual  sides  to  the  margin  of  the  gum,  then 
place  on  the  clamp,  which  will  hold  all  in  position. 

This  properly  done,  all  moisture  will  be  effectually 
excluded;  success  in  this,  however,  depends  some- 
what on  the  accurate  adaptation  of  the  clamp  to  the 
tooth.  If  the  rubber  can  be  readily  passed  between 
this  and  either  or  both  of  the  contiguous  teeth,  it  is 
well  to  do  so,  thus  making  the  work  more  secure,  if 
the  clamp  should  be  defective  in  adaptation.  When 
the    mouth   is    small,    or    not    properly    controlled, 


FILLING   BY    CLASSES    AND    MODIFICATIONS.  225 

greater  precaution  will  be  requisite ;  in  such  cases 
the  rubber  should  always  be  passed  between  the 
teeth,  and  in  some  instances  over  one  or  two  neigh- 
boring teeth,  in  order  that  the  operation  may  not  be 
embarrassed  by  encroachment  of  the  rubber.  But  in 
no  case  should  it  be  placed  upon  more  teeth  than  is 
necessary  to  meet  the  demands  of  the  case.  The 
free  border  of  the  rubber  should  now  have  the  bands 
and  weights  applied,  so  that  the  utmost  freedom 
of  approach  may  be  made  to  the  point  of  opera- 
tion. The  cavity  should  be  thoroughly  dried  with 
bibulous  paper  and  the  warm  air  blow-pipe,  when  a 
minute  examination  of  the  cavity,  at  every  point  and 
in  every  particular,  should  be  made,  and  any  imper- 
fections remedied.  And  now,  with  the  automatic 
saliva  extractor  in  place  and  operating,  the  work  of 
introducing  the  filling  may  proceed. 

In  some  small  simple  cavities  of  this  class,  in  the 
upper  teeth,  with  conditions  favorable,  and  but  a  short" 
time  required  for  introducing  the  filling,  the  following 
arrangement  may  serve  the  purpose  :  Wipe  dry  the 
mucous  membrane  about  the  mouth  of  the  duct  of 
Steno ;  lay  directly  upon  this  a  piece  of  heavy  blotting 
paper,  or  a  roll  of  bibulous  paper ;  then  take  a  napkin 
folded  cornerwise,  pbce  the  end  of  it  upon  the  paper, 
between  the  cheek  and  the  gum,  passing  it  back  of  the 
tooth  to  be  operated  upon,  along  the  palatal  surfaces 


226  CLASSIFICATION    OF    DECAYED    CAVITIES. 

of  the  teeth  and  the  gums  to  the  anterior  part  of  the 
mouth,  and  letting  a  fold  of  it  extend  down  from 
this,  and  out  over  the  inferior  front  teeth  and  the 
lip,  so  as  to  i^rotect  the  tooth  from  the  breath,  and 
catch  any  fragments  of  gold  that  may  drop  from  the 
instrument.  The  napkin  and  paper,  thus  arranged,  are 
to  be  kept  in  their  place  by  the  fingers  of  the  left 
hand  of  the  operator;  and  if  the  mouth  of  the  duct 
is  kept  closed  by  the  paper,  a  complete  exclusion  of 
moisture  is  secured,  so  far  as  that  source  is  con- 
cerned. In  some  cases  pressure  of  the  fingers  on  the 
naj)kin  over  the  duct  is  necessary ;  in  others,  the 
paper  adheres  to  the  mucous  membrane,  and  effectu- 
ally prevents  the  egress  of  saliva.  The  cavity  should 
now  be  dried  by  the  method  heretofore  described, 
and  it  is  ready  for  the  filling. 

In  the  absence  of  the  automatic  saliva  extractor, 
the  saliva  pump  represented  in  Figure  84  will  serve 

Fig.  84. 


a  valuable  purpose,  though  it  does  not  completely 
fulfill  the  requirements. 

An  instrument  invented   by  Dr.   W.   II.  Dibble, 
called  "  Dibble's  Saliva  Pump,"  performs  the  work  of 


£ 


FILLING    BY    CLASSES    AND    MODIFICATIONS. 


227 


both  the  saliva  pump  and 
tongue  holder.  As  a  saliva 
pump  it  is  much  superior 
to  the  instrument  repre- 
sented in  Fig.  84,  which 
is  in  common  use. 

It  is  operated  by  the 
patient,  and  removes  the 
saliva  immediately  after 
it  enters  the  mouth,  and 
may  be  in  constant  action, 
without  the  slightest  in- 
terruption of  the  operation 
of  filling;  the  saliva  passes 
into  a  reservoir,  and  is 
perfectly  enclosed  till  the 
operation,  however  pro- 
tracted, is  completed. 

That  part  of  the  instru- 
ment designed  to  hold  the 
tongue  and  the  buccal  sur- 
face from  the  tooth  to  be 
operated  upon,  and  to  hold 
the  jaws  apart,  is  of  a  very 
excellent  form,  and  accom- 
plishes its  work  well.  It 
is    in    three    parts,    one 


Fig.  85. 


228 


CLASSIFICATION    OF    DECAYED    CAVITIES. 


adapted  to  each  side  of  the  mouth — in  these  the 
saliva  is  taken  up  by  the  instrument  opposite  the 
lingual  surface  of  the  second  inferior  molar — and 
one  for  the  front,  with  a  compressor  passing  on 
to  the  tongue  and  holding  it  firmly  down,  and  the 
pump-tube  takes  the  saliva  from  the  immediate 
vicinity  of  the  sublingual  ducts. 

This  latter  part  of  the  instrument  is  the  device  of 
Dr.  B.  F.  Arrington.  The  instrument  is  well  repre- 
sented in  Fig.  85.  That  part  of  this  instrument  de- 
signed to  hold  down  the  tongue  is  rendered  unneces- 
sary by  the  use  of  the  rubber  dam. 

It  is  often  the  case  that  the  finger  is  too  short  to 
reach  a  desired  point,  to  hold  down  a  napkin  or 
paper,  or  hold  away  the  soft  parts,  or  is  so  large  as 
to  fill  the  space  inconveniently,  obstructing  the  view 
of  the  operation.     To  overcome  both  of  these  difiicul- 

Fisr.  86. 


ties,  an  extension  thimble  is  used ;  it  may  be  made 
of  silver  or  rubber,  though  better  of  the  former.  In 
addition  to  the  uses  mentioned,  it  may,  by  having  a 


FILLING    BY   CLASSES   AND    MODIFICATIONS. 


229 


fine  steel  point,  be  made  to    serve  as  a  holder  to 
aid  in  introducing  fillings.      (Fig.  86.) 

Various   appliances  have   been    used   for    holding 
away  the  cheek,  keeping  down  the  tongue,  and  re- 


Fig.  87. 


taining  the  jaws  apart.     An  instrument  for  this  pur- 
pose is  shown  in  Fig.  87. 

Fining  with  Foil. — If  non-cohesive  gold  is  employed, 
it  should  be  formed  into  blocks,  by  cutting  from  four 
to  eight  thicknesses  into  strips  one  fourth  wider  than 
the  cavity  is  deep,  and  rolling  them  on  a  broach 
suitable  for  the  purpose,  into  cylindrical  blocks  cor- 
responding in  size  with  the  cavity  to  be  filled,  and 
varying  not  only  in  size,  but  in  form  and  density. 
The  blocks  first  to  be  introduced  should  be  largest, 
followed  by  those  diminishing  in  size,  the  last  por- 
tions being  small,  dense,  conical  rolls.  Where  there 
is  an  inward  or  outward  inclination  of  the  walls  of 
the  cavity,  the  first  blocks  should  be  cone-shaped. 
For  introducing  the   blocks,  the  plugging  pliers  will 


230  CLASSIFICATION    OF    DECAYED    CAVITIES. 

be  required.  The  first  block  is  taken  up  with  this 
instrument  and  placed  against  the  posterior  wall  of 
the  cavity,  with  one  end  on  the  bottom  and  the  other 
protruding  from  the  orifice,  and  there  compressed 
firmly  to  its  place  with  the  appropriate  condensing 
instrument ;  and,  unless  there  is  some  special  retain- 
ing point,  it  may  be  necessary  to  hold  it  in  its  posi- 
tion with  a  second  instrument,  till  the  next  portion 
is  added.  As  the  successive  blocks  are  introduced, 
each  is  to  be  thoroughly  consolidated,  so  as  to  be 
immovable.  The  filling  is  to  proceed  from  the  pos- 
terior wall  to  the  centre.  After  the  cavity  has  thus 
been  filled  to  the  centre,  commence  in  the  same 
manner  at  the  anterior  wall,  filling  from  thence 
toward  the  centre,  and  condensing  the  last  blocks 
by  forcing  in  at  their  side  a  small  sharp-pointed 
instrument ;  the  final  portion  introduced  will  be  the 
small,  dense,  conical  roll  already  mentioned.  The 
gold  being  all  introduced,  a  smooth-pointed  instru- 
ment or  burnisher  condenses  the  projecting  portion 
of  the  filling  till  it  is  perfectly  solid,  when  it  is 
finished  with  a  file,  stone  and  burnisher  in  the 
manner  already  described.  The  particular  shape  of 
the  surface  of  the  filling  will  be  suggested  by  the 
form  of  the  antagonizing  tooth.  Usually  the  surface  of 
these  fillings  should  be  slightly  concave ;  in  some  cases 
the  occlusion  of  the  teeth  is  such  as  to  require  very 


I 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  231 

considerable  concavity ;  this,  however,  should  only  be 
sufficient  to  accommodate  the  closure  of  the  teeth. 

For  dressing  down  the  burs,  corundum  cones, 
Scotch  stone  and  buff  cones  used  with  the  engine, 
represented  by  Figs.  28  and  29,  will  serve  the  pur- 
pose most  fully. 

Cohesive  Foil. — For  filling  these  cavities  with  co- 
hesive foil,  definite  retaining-points  should  be  formed 
in  them,  or  the  bottom  of  the  cavity  of  such  a  form 
as  to  retain  firmly  in  position  the  first  pieces  of  gold 
introduced.  The  gold,  prepared  in  the  manner 
already  described,  is  taken  up  with  a  serrate-pointed 
plugger  or  plugging  pliers,  introduced  into  the  re- 
taining point  or  points,  and  there  fixed ;  it  is  then 
built  across  from  one  to  the  other,  and  over  the  floor 
of  the  cavity  till  this  is  completely  covered,  and  then 
up  from  the  bottom  to  the  orifice.  When  a  portion 
of  gold  is  taken  on  the  point  of  the  instrument,  the 
precise  spot  at  which  to  deposit  it  should  be  selected, 
and  there  it  should  be  placed,  and,  by  the  first 
pressure  of  the  instrument,  fixed  immovably ;  a 
few  subsequent  strokes  of  the  instrument,  near  the 
first  point  of  attachment,  will  be  required.  These 
strokes  should  be  close,  because  if  the  instrument  is 
lifted  up  and  pressed  upon  the  piece  at  a  distance 
from  the  first  point  of  contact,  the  attachment  is 
liable  to  be  broken.     The  character  of  the  gold,  and 


232  CLASSIFICATION    OF    DECAYED    CAVITIES. 

the  condition  of  the  receiving  surface  will  govern  to 
some  extent  the  precise  method  of  manipulation. 
Very  much  depends  upon  keeping  the  surface  in 
a  good  condition  for  the  reception  of  the  gold  to  be 
added.  The  best  receiving  surface  is  obtained  by 
having  the  condensing  instrument  sharp  and  in  good 
condition,  and  then  in  using  it,  let  there  be  a  little 
space  between  its  impressions — the  surface  not 
stamped  completely  over  by  the  condensing  instru- 
ment. In  constructing  the  filling,  we  consider  it 
preferable  to  keej)  it  built  up  a  little  higher  all 
around  next  the  walls  than  at  the  centre,  for  the 
reason  that  a  more  complete  adaptation  of  the  gold 
can  thus  be  made  than  by  any  other  plan.  Some, 
however,  advocate  the  opposite  practice;  that  is,  of 
keeping  the  filling  higher  in  the  centre  than  at  the 
walls,  and  thus  forming  an  angular  space  into  which 
to  crowd  the  gold ;  because  the  gold  is  thus  kept  in 
more  thorough  contact  with  the  walls  of  the  cavity; 
and  it  is  objected  that,  to  add  and  consolidate  the 
gold  to  the  centre,  while  the  edges  are  left  higher, 
tends  to  draw  them  from  the  walls.  This  objection, 
however,  has  no  force,  if  the  gold  is  thoroughly  con- 
solidated as  it  is  introduced. 

The  cavity  is  thus  filled  up,  consolidated,  and 
finished  in  the  usual  manner.  In  adding  the  last 
portions  of  gold,  great  care  should  be  taken  to  make 


FILLING    BY   CLASSES    AND    MODIFICATIONS.  233 

a  perfect  border  to  the  filling.  Crystal  gold  may  be 
very  advantageously  used  as  a  foundation  for  cohe- 
sive foil  fillings,  as  it  will  retain  its  position  perfectly 
in  a  cavity,  where  foil  will  not. 

Crystal  Gold. — The  method  of  filling  this  class  of 
cavities  with  crystal  gold  is  very  simple.  The  mate- 
rial should  be  annealed  just  before  its  use,  and  then 
cut  or  broken  into  blocks  corresponding  with  the  size 
of  the  cavity  to  be  filled ;  they  may  be  used  as  large 
as  will  freely  enter  the  cavity;  many  small  pieces 
will  be  required  to  fill  up  interstices  or  angles.  The 
filling  may  be  commenced  at  the  bottom  of  the  cavity, 
and  built  up  from  that  to  the  orifice,  the  same  plan 
being  followed  in  adapting  it  to  the  walls  as  with  co- 
hesive foil,  the  pieces  being  passed  into  the  cavity 
with  either  the  plugging  pliers  or  a  condensing  in- 
strument. Each  piece  should  be  well  consolidated 
before  another  is  added.  For  condensing  the  filling- 
next  to  the  walls,  a  small  wedge-shaped  instrument  is 
valuable.  In  all  cases  where  there  is  a  divergence 
of  the  anterior  wall,  much  care  is  required  in  order  to 
make  a  perfect  filling ;  and  too  much  care  cannot  be 
exercised  in  perfecting  the  filling  round  the  border  of 
the  cavity.  In  condensing  cohesive  foil  or  crystal 
gold,  the  force  may  be  applied  almost  exclusively  in 
a  line  with  the  axis  of  the  tooth ;  and  this  is  always 
preferable  to  lateral  pressure. 


234  CLASSIFICATION    OF    DECAYED    CAVITIES. 

1st  Mod. — Extension  of  decay  along  one  or  more 
of  the  crown  fissures.  In  a  case  of  this  kind,  the 
central  cavity  is  first  to  be  opened  and  excavated, 
according  to  the  principles  already  announced.  Decay 
in  the  fissures  is  in  some  cases  an  extension  of  this 
central  decay,  and  at  the  point  of  its  termination 
there  will  be  found  an  acute  angle ;  but  in  others,  it 
will  be  the  effect  of  an  equal  attack  all  along  the 
fissure,  or  of  an  extension  from  some  other  point 
than  the  central  cavity.  This  modification  of  decay 
may  terminate  either  in  an  acute  angle  or  in  an 
expansion. 

These  decayed  fissures  should  be  opened  up  by 
cutting  away  any  projecting  portion  of  enamel,  and 
the  cavities  formed  with  a  small  chisel-shaped  instru- 
ment, beginning  at  the  juncture  of  the  fissure  with 
the  main  cavity,  and  cutting  down  to  the  bottom  of 
the  decay  in  the  manner  of  a  mortise,  thus  cutting 
out  the  entire  fissure  and  the  acute  angle  at  its  ter- 
mination— the  latter  an  important  consideration.  In 
case  there  is  a  very  considerable  expansion  of  decay 
at  the  termination  of  the  fissure,  the  bur  drill  may  be 
introduced  into  it,  and  the  rest  of  the  fissure  cut  out, 
as  the  form  of  the  cavity  may  indicate.  In  exca- 
vating and  forming  these  fissures,  the  burs  made  for 
the  purpose  (shown  in  Fig.  22),  and  used  with  the 
engine,  give  greater  facility  and  rapidity  of  execution 


FILLING   BY    CLASSES    AND    MODIFICATIONS.  235 

than  by  the  method  just  described,  and  with  care, 
equally  as  definite  results. 

If  blocks  are  used  to  fill  these  cavities,  they  should 
be  set  in  and  compressed  against  the  end  of  the  fis- 
sure, protruding  from  it  sufficiently  to  admit  of  a 
proper  finish ;  and  block  after  block  added,  till  the 
fissure  is  filled  up  to  the  main  cavity.  Where  there 
are  two  or  three  of  these  decayed  fissures  in  one 
tooth,  it  may  be  quite  as  much  as  can  be  done  at 
one  sitting  to  fill  them,  the  main  cavity  being  left 
for  another  time.  In  such  cases,  the  filling  introduced 
at  the  first  sitting  should  then  be  consolidated  and 
burnished,  so  that  it  may  not  absorb  moisture  while 
the  main  cavity  is  filled,  as  already  described.  Much 
care  should  be  exercised  to  prevent  the  gold  from 
overlapping  the  enamel  at  the  sides  of  these  fissures. 
In  filling  this  modification  with  crystal  gold  or  an- 
nealed foil,  it  is  better  to  begin  at  the  bottom  of  the 
cavity  and  build  up  to  the  orifice,  first  completing 
the  fissure,  as  we  have  already  described,  and  after- 
ward the  main  cavity. 

2c?  Mod. — Two  cavities  on  the  same  crown  in  close 
proximity.  The  thickness  of  the  portion  of  tooth  in- 
tervening between  two  cavities  on  the  grinding  sur- 
face of  the  same  croWn  is  determined  by  the  location 
and  extent  of  the  decay  and  by  the  form  of  the 
cavities ;  and  these  two  conditions  will  suggest  the 


236  CLASSIFICATION    OF    DECAYED    CAVITIES. 

method  of  operation.  If  this  intervening  portion  is 
thin  throughout,  and  devoid  of  vitality,  it  should  be 
cut  away,  and  the  two  cavities  formed  into  one ;  but 
if  it  is  thick  within,  though  it  may  be  thin  at  the 
surface,  the  cavities  should  be  filled  separately.  In 
some  cases  it  is  proper  to  leave  a  part  of  it  standing, 
as  a  sort  of  ridge  between  the  cavities,  though  not  as 
a  definite  partition ;  in  which  case  the  filling  would  be 
commenced  as  in  two  cavities,  and  finished  as  in  one. 
In  no  case,  however,  when  the  tooth  is  living,  should 
this  intervening  portion  remain,  if  its  vitality  is  gone. 
The  details  of  the  process  of  filling  crown  cavities 
have  already  been  indicated. 

Second  Class. — Buccal  and  palatal  cavities  of  the 
molars  and  bicuspids,  and  labial  and  palatal  cavities 
of  the  canines  and  incisors.  In  the  molars,  this  class 
of  decay  begins  either  at  the  margin  of  the  gum,  in 
the  form  of  a  transverse  groove,  or  along  the  vertical 
depression  on  the  buccal  surface  of  the  tooth,  or  at 
its  termination.  These  groove-like  decays,  extending 
along  the  side  of  the  tooth  at  or  near  the  margin  of 
the  gum,  are  ordinarily  not  very  deep ;  but  they 
burrow  considerably  under  the  enamel,  particularly 
at  the  side  next  the  grinding  surface.  In  preparing 
these  cavities,  the  projecting  jjortion  of  the  enamel 
must  bo  mostly  cut  away,  leaving  them  but  slightly 
larger  within  than  at  the  orifice.     These  grooves,  at 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  237 

their  ends,  are  shallow ;  but  in  their  preparation  for 
filling,  they  should  be  cut  as  deep  at  the  ends  as 
elsewhere,  and  when  the  main  part  of  the  cavity  is 
comparatively  shallow,  deeper.  Much  difficulty  is 
often  experienced  in  protecting  these  cavities  from 
moisture  while  being  filled.  The  rubber  dam,  when 
well  applied,  accomplishes  the  object  better  than  any 
other  appliance ;  it  is  in  such  cases  invaluable. 

The  method  of  introducing  gold  in  the  form  of 
blocks  into  these  cavities,  is  to  set  in  the  first  block 
at  the  posterior  part  of  the  cavity,  and  consolidate  it, 
and  so  one  block  after  another  till  the  cavity  is 
nearly  full ;  and  then  proceed  in  like  manner  with 
the  anterior  end,  back  toward  the  middle,  the  blocks, 
of  course,  being  permitted  to  protrude  sufficiently  for 
the  purposes  of  a  finish.  For  filling  with  crystal 
gold  or  cohesive  foil,  the  method  is,  to  form  pits  at 
the  end  of  the  groove,  into  which  the  gold  is  consoli- 
dated, and  built  across  from  one  to  the  other,  and 
then  up  from  the  bottom  to  the  orifice,  when  it  is 
finished  as  usual.  Care  is  requisite  to  prevent  the 
gold  from  overlapping  the  tooth  outside  of  the  cavity. 
Any  projection  of  the  filling",  especially  beyond  the 
margin  of  the  cervical  wall  of  the  cavity,  is  very  ob- 
jectionable ;  it  would  afford  a  lodgment  for  extra- 
neous substances,  the  tendency  of  which  is  to  pro- 
duce irritation  and  decay. 


238  CLASSIFICATION    OF   DECAYED    CAVITIES. 

Cavities  of  this  class,  which  are  formed  in  the  de- 
pressions of  the  buccal  portions  of  the  teeth,  are 
more  easily  filled.  Often  a  simple  round  cavity  is 
formed  at  the  coronal  termination  of  this  depression, 
which  may  be  entirely  prepared  with  a  bur  drill. 
The  method  of  filling  these  cavities  will  be  readily 
inferred  from  the  remarks  before  made.  If,  however, 
the  decay  extends  along  the  depressions,  making  a 
groove-like  cavity,  this  should  be  filled  by  com- 
mencing the  introduction  of  the  gold  at  that  part  of 
the  cavity  next  the  gum. 

1st  Mod. — Decay  at  or  near  the  neck  of  the  tooth, 
and  partially  or  wholly  overlapped  by  the  free  border 
of  the  gum.  In  this  modification  the  gum  is  a  great 
obstacle  to  the  various  steps  in  the  process  of  filling. 
It  is  liable  to  be  wounded  and  to  bleed  at  every 
touch  ;  it  exudes  mucus  constantly ;  and  it  conducts 
saliva  to  the  part  with  great  facility.  To  obviate 
these  difficulties,  the  gum  must  be  removed  some- 
what from  the  cavity  before  the  filling  is  practicable. 
This  removal  of  the  free  margin  of  the  gum  may  be 
made  either  by  cutting  away,  or  by  pressing  away 
with  pledgets  of  cotton  or  other  appropriate  substance 
placed  in  the  cavity  and  projecting  from  it,  so  as  to 
make  pressure  upon  and  absorption  of,  to  a  sufficient 
extent,  the  free  margin  of  the  gum,  which  will 
usually  be  accomplished  in  a  day  or  two.     The  for- 


I 


FILLING   BY    CLASSES    AND    MODIFICATIONS.  239 

raer  method,  however,  accomplishes  the  object  at 
once :  some  good  hemostatic,  as  creasote  and  tannin, 
is  all  that  is  then  necessary  to  render  the  filling 
immediately  practicable.  By  means  of  this  applica- 
tion the  exudation  is  checked, — which,  where  there  is 
much  mucus  eliminated,  is  an  important  item, — and 
also  such  a  surface  is  given  to  the  part  that  it  will  not 
so  readily  conduct  the  saliva.  It  is  perhaps  prefer- 
able in  many  cases  to  cut  away  this  free  margin,  so 
that  it  shall  not  be  in  contact  with  the  filling  after 
the  operation  is  completed.  In  nearly  all  such 
cases,  by  the  proper  application  of  the  rubber  dam 
with  a  perfectly-adapted  clamp,  the  whole  difliculty 
will  be  overcome. 

After  this  preparation,  the  cavity  is  formed  and 
filled  as  usual. 

In  filling  cavities  of  the  buccal  portions  of  the 
denies  sapientice,  peculiar  difficulties  are  met  with. 
The  decay  is  frequently  found  two-thirds  covered 
by  the  gum;  the  muscles  of  the  cheek,  thick  and 
rigid,  lie  close  against  the  side  of  the  tooth  ;  and,  in 
most  cases  of  this  kind,  the  view,  at  best,  is  but  par- 
tial. To  meet  this  difficulty,  a  clamp  with  a  broad 
flange  upon  its  outer  blade  is  required  for  holding  the 
soft  parts  away,  and  the  rubber  dam  in  its  proper 
position. 

In  nearly  all  such  cases  the  reflector  should  be 


240  CLASSIFICATION    OF    DECAYED    CAVITIES. 

used  to  concentrate  light  upon  the  locality  of  the 
operation ;  without  this,  the  view  into  these  cavities 
is  much  ohscured. 

Third  Class. — Anterior  proximal  cavities  of  the 
molars  and  bicuspids.  This  class  of  cavities  in  teeth 
with  short,  broad  crowns,  takes  place  at  their  necks ; 
but  in  those  with  long  crowns,  and  with  a  diameter 
less  at  the  neck  than  at  the  masticating  surffice,  it 
begins  at  some  distance  from  the  neck,  toward  the 
crown  surface,  or  at  the  first  point  of  contact  of  the 
crowns.  In  almost  all  cases  of  proximal  fillings  sepa- 
ration of  the  teeth  is  required ;  the  method  and  ex- 
tent of  this  will  be  determined  by  circumstances.  If 
all  the  neighboring  teeth  stand  in  contact,  it  cannot 
be  easily  accomplished  by  pressure ;  in  this  respect, 
however,  there  will  be  found  a  great  variety ;  but  if 
a  tooth  has  been  extracted  in  the  vicinity,  or  there 
are  natural  spaces  between  the  others,  it  can  be 
either  in  whole  or  in  part.  When,  however,  the 
teeth  stand  close  togethei',  they  must  in  such  case 
be  separated  chiefly  with  the  chisel  and  file.  If  but 
one  is  decayed,  the  cutting  should  be  exclusively 
from  that.  If  two  are  alike  affected  on  their  proximal 
surfaces,  it  should  be  mostly  from  the  posterior  sur- 
face of  the  anterior  tooth.  In  regard  to  the  form  of 
the  separation  effected  by  cutting,  the  general  prac- 
tice formerly  was  to  cut  down  the  whole  proximal 


I 


FILLING   BY   CLASSES    AND   MODIFICATIONS.  241 

side  of  the  affected  tooth,  making  between  it  and  the. 
adjoining  one  a  V-shaped  space,  sufficient  in  extent 
to  admit  of  free  manipulation  in  all  parts  of  the  ope- 
ration of  filling.  By  thus  cutting  the  teeth,  the  form 
is  marred,  and  often  to  great  disadvantage  in  use,  as 
by  it  the  masticating  surface  is  lessened,  and  food 
being  crowded  into  such  a  space,  produces  very  un- 
pleasant pressure.  In  order  to  preserve  the  form 
and  the  greatest  amount  of  masticating  surface  to 
the  tooth,  a  preferable  method  is  to  cut  down  from 
the  masticating  surface  to  the  cavity  of  decay,  leaving 
the  lingual  and  buccal  sides  of  the  tooth  untouched, 
except,  perhaps,  a  little  dressing  that*  may  be  ren- 
dered necessary  by  the  thinness  and  roughness  of 
the  margins.  This  cutting  should  extend  about  as 
far  toward  the  centre  of  the  tooth  as  the  decay  has 
penetrated,  and  be  nearly  as  wide  as  the  extent  of 
the  decay  across  the  tooth ;  it  should  be  of  dove- 
tail form,  or  that  part  of  the  opening  next  to  the 
centre  of  the  crown  slightly  wider  than  at  the  ante- 
rior part.  This  form  may  very  readily  be  given  by 
the  properly-formed  excavators,  or  more  rapidly,  and 
quite  as  well,  with  the  fissure  burs  and  engine.  Care 
should  be  exercised  in  this  particular  lest  the  lateral 
walls  of  the  cavity  be  weakened  by  this  cutting ;  and 
in  doubtful  cases,  rather  than  incur  such  risk,  it  is 
better  to  avoid  making  the  expansion  altogether,  and 

Q 


242  CLASSIFICATION   OF   DECAYED   CAVITIES. 

relj  upon  other  modes  of  anchorage  for  the  filling. 
The  attachment  of  the  filling  may  be  made  by  pro- 
perly-located pits  and  grooves.  In  making  these, 
two  points  should  be  guarded,  viz. :  weakening  the 
walls  of  the  cavity,  and  impingement  upon  the  pulp. 
Care,  good  judgment  and  experience  are  necessary  to 
most  fully  meet  these  requirements.  When  it  is 
necessary  to  cut  from  the  whole  proximal  surface, 
there  should  be  no  shoulder  or  projection  left  at  the 
neck  of  the  tooth,  but  the  cut  surface  should  be  plain 
from  the  crown  to  its  termination  at  or  near  the 
neck.  The  space,  of  whatever  form  it  may  be,  should 
be  large  enough  to  enable  the  operator  to  manipulate 
with  facility,  and  to  see  as  directly  as  possible  into 
the  cavity. 

Cavities  of  this  class  are  various  in  form ;  and  they 
require  much  skill  in  their  excavation  and  formation. 
Great  care  is  to  be  exercised  not  to  leave  any  portion 
of  decay  in  them.  By  a  fatal  oversight,  decayed 
dentine  is  often  permitted  to  remain  on  that  side 
next  to  the  neck  of  the  tooth  ;  and  fillings  that  in 
other  respects  are  good,  are  very  deficient  here — so 
deficient,  indeed,  that  a  sharp  instrument  will  readily 
penetrate  the  softened  dentine  above  them,  or  even 
pass  between  the  filling  and  the  wall  of  the  cavity. 
The  removal  of  the  decay  from  the  cervical  walls  of 
all  proximal  cavities  is  an  important  particular,  neg- 


FILLING   BY   CLASSES   AND   MODIFICATIONS.  243 

lect  of  which  occasions  thousands  of  failures.  This 
class  of  cavities  at  this  point  should  be  most  thor- 
oughly filled ;  for  it  is  a  point  more  vulnerable  than 
any  other,  on  account  of  the  facility  with  which  for- 
eign substances  are  here  lodged  and  retained. 

In  the  formation  of  these  cavities,  the  cervical  wall 
should  be  made  to  incline  slightly  outward,  and  the 
lateral  walls,  if  the  tooth  will  bear  the  loss,  made  at 
least  parallel  with  each  other ;  but  if  that  would  im- 
pair its  strength,  grooves  or  pits  may  be  made  upon 
them  for  this  purpose  at  proper  points.  When  these 
cavities  are  large,  the  dentine  is  usually  all  decayed 
in  that  part  of  the  cavity  next  to  the  masticating 
surface  of  the  tooth,  leaving  only  the  enamel,  which 
by  the  mode  of  separating  or  opening,  already  de- 
scribed, would  be  cut  away. 

The  rubber  dam  being  properly  adjusted,  the  cavity 
is  ready  for  the  filling,  which  is  introduced,  if  in 
blocks,  as  before  detailed,  beginning  with  the  cervi- 
cal wall.  The  caution  may  here  again  be  urged,  not 
to  let  the  gold  overlap  the  tooth,  particularly  at  the 
cervical  wall.  In  filling  with  crystal  gold  or  cohe- 
sive foil,  special  retaining  points  will  be  required  in 
this  wall,  two  being  generally  sufficient,  one  toward 
the  outer  and  the  other  toward  the  inner  lateral  wall, 
on  both  of  which  grooves  may  be  made,  if  the  walls 
are  thick  enough  to  admit  of  it.     If,  however,  these 


244  CLASSIFICATION    OF   DECAYED   CAVITIES. 

walls  are  not  parallel,  and  will  not  admit  of  grooves, 
the  crown  and  the  cervical  walls  should  be  so  shaped 
as  to  retain  the  filling.  But  in  some  cases  the 
attachment  of  the  filling  is  made  entirely  at  the  cer- 
vical wall ;  and  best  by  means  of  three  pits,  made 
with  the  square-pointed  drill  at  different  angles,  and 
in  such  directions  as  not  to  interfere  with  the  pulp. 
This  kind  of  attachment  will  serve  only  for  cohesive 
gold,  which  is  to  be  very  thoroughly  consolidated 
into  the  pits,  making  little  projections,  which  are  so 
many  anchors  for  fastening  the  filling,  and  built  very 
firmly  across  from  one  to  the  other. 

2d  Mod. — Decay  involving  a  portion  of  the  masti- 
cating surface.  There  are  two  methods  of  filling  this 
modification.  One  is,  to  cut  down  the  tooth  or  the 
projecting  angles,  and  make  a  plain,  oblique  border 
to  the  cavity  by  the  V-shaped  separation  ali-eady  re- 
ferred to,  and  then  fill  up  flush  with  this  border. 
The  filling  will  thus  exhibit  a  single,  uniform  surface, 
at  a  considerable  angle  with  the  axis  of  the  tooth. 
AVhen  a  portion  of  the  crown  breaks  down  in  conse- 
quence of  proximal  decay,  it  is  toward  the  centre  of 
the  tooth;  usually  the  inner  and  outer  corners  re- 
main. If  these  projections  are  feeble  and  liable  to 
be  broken  away,  they  should  be  cut  down  and  the 
cavity  filled  as  before  described.  If,  however,  they 
are  firm,  they  should  remain,  and  the  cavity,  pro- 


\ 


FILLING   BY   CLASSES   AND   MODIFICATIONS.  245 

perly  formed,  may  be  filled  so  as  to  restore  the 
tooth's  original  form,  which  in  the  molars  and  bicus- 
pids should  be  accomplished  as  nearly  as  possible,  in 
order  that  the  function  of  mastication  should  be  per- 
fectly preserved.  By  properly-directed  effort,  the 
crowns  of  the  teeth  can  in  almost  all  cases,  even 
where  the  walls  are  broken  away,  be  well  restored. 
Non-cohesive  foil  is  not  adaptable  to  this  kind  of 
filling,  as  it  cannot  be  built  in  so  as  to  withstand  the 
pressure  of  mastication.  In  no  case  should  a  proxi- 
mal filling  be  left  in  contact  with  the  adjoining  tooth. 
Fourth  Class. — Proximal  cavities  of  the  incisors 
and  cuspidati.  If  the  teeth  are  not  in  a  crowded 
condition,  and  the  file  is  not  required  by  the  extent 
of  the  decay,  separation  may  be  made  by  pressure ; 
but  if  the  cavity  is  large,  and  the  walls  are  thin  and 
friable,  cut  with  a  thin  chisel  and  file  only  till  a  good 
border  is  obtained  about  the  cavity.  Much  has  been 
said  as  to  the  form  of  these  separations,  some  recom- 
mending that  they  be  larger  at  the  palatine  part 
than  at  the  labial ;  others,  that  they  be  larger  at  the 
points  than  at  the  necks  of  the  teeth ;  some,  that  a 
shoulder  be  left  at  the  necks ;  and  others,  that  there 
be  no  shoulder  at  all.  In  making  these  separations, 
however,  the  operator  must  be  governed  somewhat 
by  circumstances,  no  general  rule  being  applicable  to 
all  cases.     The  form  of  the  teeth  and  the  extent  of 


246  CLASSIFICATION    OF   DECAYED    CAVITIES. 

the  decay,  together  with  the  character  of  the  remain- 
ing enamel  and  dentine,  will  modify  the  form  of  the 
space  between  them.  If  the  inner  wall  is  thin  or 
broken  away, — and  it  is  usually  more  friable  and 
more  broken  than  the  labial  wall, — it  should  be  cut 
off  more  than  the  outer ;  in  which  case  the  palatine 
aspect  of  the  separation  will  be  the  largest — as,  in- 
deed, some  prefer  to  make  it  in  all  cases,  performing 
the  remainder  of  the  operation  from  the  inside. 
Almost  every  operation  upon  these  teeth  will  require 
attention  and  manipulation,  in  every  step,  from  both 
the  palatine  and  labial  sides,  in  order  to  make  secure 
every  point.  The  precise  mode  of  procedure  must 
be  determined  by  the  case  to  which  it  is  to  be 
applied.  The  most  direct  approach  is  always  to  be 
employed  when  practicable. 

In  some  cases  separation  will  be  larger  at  the 
points  of  the  teeth  than  elsewhere ;  as,  where  there 
has  been  a  partial  fracture  at  the  points.  In  cutting 
away  to  make  the  separation,  no  shoulder  should  be 
left  at  the  neck  of  the  tooth  that  is  not  to  be  pro- 
tected by  filling;  any  projection  of  that  kind  is 
always  objectionable  :  foreign  substances  lodge  upon 
and  adhere  to  it,  and,  becoming  vitiated,  render  it 
very  liable  to  decay.  The  cutting  should  always  ex- 
tend entirely  beyond  the  decay,  but  only  far  enough 
to  make  a  perfectly  plain  border  to  all  the  cavity. 


I 


FILLING    BY   CLASSES    AND    MODIFICATIONS.  247 

and  should  terminate  without  any  projection.  It  is 
highly  important,  in  separating  the  anterior  teeth,  to 
make  as  little  alteration  as  possible  in  their  form. 
But  the  preservation  of  the  tooth  should  not  be 
jeopardized  for  the  sake  of  maintaining  the  integrity 
of  its  natural  form.  The  first  consideration  should 
be  to  obtain  a  space  sufficient  for  the  purposes  of  a 
perfect  operation ;  the  second,  to  have  the  walls  and 
border  of  the  cavity  in  such  a  condition  that  an  effi- 
cient filling  can  be  made ;  and  the  form  and  beauty 
of  the  tooth  should  be  scrupulously  preserved  and 
protected,  so  far  as  the  above  requirements  will 
permit. 

The  excavation  of  these  cavities  requires  very 
delicate  and  skillful  manipulation,  since  they  are 
very  readily  injured  by  cutting  too  much  or  at  a 
wrong  point.  All  decayed  and  discolored  portions 
must  be  entirely  removed,  as  well  for  the  appearance 
of  the  tooth  as  for  the  permanency  of  the  operation ; 
after  which  the  cavity  is  to  be  formed  with  great 
care.  Toward  the  cutting  edge  of  the  tooth  the  den- 
tine often  has  all  been  displaced  by  decay,  leaving 
only  the  two  plates  of  enamel  joined  at  the  edge,  and 
thus  forming  an  acute  angle,  the  obliteration  of  which 
is  always  attended  with  risk,  unless  great  care  is 
exercised,  and  in  many  teeth  it  is  wholly  impracti- 
cable ;  and  still  it  is  difficult  perfectly  to  fill  such 


248  CLASSIFICATION    OF   DECAYED    CAVITIES. 

an  acute  angle.  The  inclination  of  the  inner  and  the 
outer  walls  of  the  cavity  will  depend  on  its  size ; 
when  it  is  small  or  medium,  they  may  be  parallel, 
or,  if  necessary,  slightly  divergent  inward;  hut 
when  large,  it  is  better  not  to  cut  much  of  the 
healthy  dentine  from  them,  lest  they  be  thus  weak- 
ened. Small  grooves,  however,  are  admissible  on 
these  walls,  near  the  bottom  of  the  cavity,  w^hen  they 
incline  to  the  centre,  and  are  generally,  in  such  case, 
to  be  preferred  to  pits.  In  the  formation  of  grooves 
or  pits  for  anchorages,  the  dentine  should  never  be 
cut  through  to  the  enamel ;  but  always  dentine  suffi- 
cient to  protect  the  enamel  should  remain.  More 
cutting  is  allowable  on  the  cervical  wall  than  else- 
where, as  there  is  less  danger  here  of  weakening  the 
tooth  by  excavation.  In  some  instances  the  cavity, 
upon  the  removal  of  the  decay,  is  of  such  extent  and 
form  as  to  admit  of  little  or  no  excavation,  except  in 
the  cervical  wall ;  in  this,  then,  the  chief  anchorage 
is  to  be  made,  and  almost  the  entire  reliance  for  the 
retention  of  the  filling  must  be  placed  upon  that 
part.  Such  a  condition  renders  the  use  of  cohesive 
gold  a  necessity,  at  least  if  a  permanent  result  is  to 
be  attained.  The  best  method  of  preparing  such  a 
cavity  is  to  make  two  or  three  little  pits  in  it  at 
different  angles  with  a  fine,  square-pointed  drill. 
Another  method  is,  to  form  two  pits,  and  make  a 


FILLING   BY   CLASSES   AND    MODIFICATIONS.  249 

groove  from  one  to  the  other.  Some  operators  pre- 
pare these  cavities  by  making  pits  in  each  of  the 
walls.  This,  however,  is  unnecessary,  if  the  cervical 
wall  is  properly  prepared. 

In  the  application  of  the  rubber  dam  for  filling 
this  class  of  cavities,  three,  four,  or  more  teeth  should 
generally  be  included,  in  order  that  there  sliall  be 
absolute  security  against  moisture,  and  that  the  rub- 
ber shall  be  out  of  the  Avay  of  the  operation.  The 
gold,  prepared  as  already  described,  should  then  be 
introduced  with  a  small  plugger,  serrated  and  some- 
what flattened  about  a  line  above  the  point,  so  as  to 
be  freely  used  when  introduced  into  the  cavity. 
The  gold  is  taken  up  on  the  point  of  this  plugger,  and 
condensed  in  the  pits  of  the  cervical  wall :  which, 
being  completely  filled,  and  the  gold  extending  from 
one  to  the  other,  the  foundation  is  ready  for  the 
remainder  of  the  filling. 

Great  care  is  requisite  in  packing  the  gold  into 
these  cavities,  perfectly  to  adapt  and  adjust  it  to  all 
points,  so  as  to  insure  its  thorough  contact  with 
every  part  of  the  interior.  If  the  form  of  the  tooth 
has  been  measurably  retained,  and  the  border  of  the 
cavity  is  even,  the  surface  of  the  plug  should,  when 
finished,  be  slightly  convex,  or  as  nearly  the  original 
form  of  the  tooth  as  practicable.  In  introducing 
the  filling,  reference  should  be  had  to  this  particular. 


250  CLASSIFICATION    OF   DECAYED    CAVITIES. 

Two-thirds  of  the  cavity  may  be  filled  by  introducing 
the  gold  upon  and  in  the  direction  of  this  cervical 
wall,  and  the  remaining  portion  filled  from  the  point 
back  to  the  preceding  filling;  or,  what  is  probably 
better,  begin  at  the  bottom  and  fill  to  the  surface,  and 
then  finish  in  the  usual  manner. 

For  filling  these  cavities  with  non-cohesive  foil,  the 
special  retaining  points  already  described  are  not  re- 
quired ;  but  the  cervical  wall  of  the  cavity  is  slightly 
cut  under,  and  the  lateral  walls  so  shaped  as  to 
secure  the  filling  in  place.  These  cavities  are  in 
some  cases  very  difficult  to  fill  with  non-cohesive 
foil,  whether  in  the  form  of  blocks  or  otherwise,  espe- 
cially where  they  are  large,  with  the  walls  inclined 
to  the  centre,  and  the  tooth  bone  friable.  To  force  a 
wedge-shaped  instrument  into  these  fillings,  for  the 
purpose  of  condensing  them,  is  not  admissible,  since 
there  is  thus  great  danger  of  breaking  the  walls  of 
the  cavity,  and  in  many  cases  of  moving  the  filling 
from  its  place. 

Ist  Mod. — The  palatal  walls  broken  away.  Frac- 
tures of  this  kind  assume  different  forms ;  sometimes 
triangular,  extending  from  the  border  of  the  cavity 
toward  the  centre  of  the  tooth,  and  terminating  in  an 
acute  angle ;  and  sometimes  the  border  of  the  cavity 
is  broken  away  irregularly,  or  so  as  to  form  part  of  a 
circle.    When  a  triangular  notch  is  broken  out  of  the 


I 


FILLING    BY   CLASSES    AND    MODIFICATIONS.  251 

wall,  the  operation  of  filling  may  be  performed  in  one 
of  two  ways :  If  the  portions  of  the  wall  remaining  at 
each  side  of  the  fracture  are  thick  and  firm,  they  may 
be  left,  and  the  cavity  filled,  so  as  to  restore  the  form 
of  both  the  proximal  and  the  palatal  surface  of  the 
tooth,  the  latter  being  thus  restored  with  gold  to  the 
extent  of  the  fracture  or  notch.  If,  however,  the  re- 
maining portions  of  the  wall  are  frail,  they  should  be 
cut  away  till  a  border  is  reached  sufficiently  firm  to 
sustain  the  filling.  Such  cutting  will  leave  the  notch 
of  a  circular  form,  and  in  many  cases  will  remove 
almost  the  whole  of  the  inner  wall  of  the  cavity.  As 
the  decay  extends  toward  the  centre  of  the  tooth, 
owing  to  the  concavity  of  its  palatal  surface,  this  wall 
becomes  very  thin  and  easily  broken,  this  rendering 
it  necessary  to  cut  it  almost  all  away;  but  in  all 
cases  the  excavation  should  be  such  as  to  leave  a 
definite  wall,  though  it  be  but  slight,  all  along  that 
part  of  the  cavity.  In  such  a  case,  good  retaining 
points  must  be  made  in  the  cervical  wall,  since  the 
permanency  of  the  filling  will  depend  almost  entirely 
upon  these. 

The  surface  of  the  filling,  when  finished,  may  be 
slightly  convex  from  one  lateral  wall  to  the  other ; 
the  palatal  portion  of  the  surface,  from  the  point  of 
the  tooth  to  its  neck,  will  partake  of  the  curvature  of 
the  border  of  the  palatal  wall ;  but  the  anterior  por- 


252  CLASSIFICATION    OF   DECAYED    CAVITIES. 

tion  will  be  flush  with  and  assume  the  outline  of  the 
anterior  border  of  the  wall.  Much  care  is  requisite 
to  give  these  filings  a  perfect  finish,  on  account  of  the 
irregularity  of  surface,  this  in  many  instances  being 
both  convex  and  concave.  As  a  material  for  filling 
these  cavities,  cohesive  gold  is  much  to  be  preferred. 
Indeed,  in  many  of  them  it  is  impossible,  with  non- 
cohesive  gold,  to  make  a  perfect  filling,  because  they 
have  no  general  embracing  form.  In  such  cases,  the 
filling  should  be  introduced  from  the  palatal  side  of 
the  tooth. 

Id  Mod. — The  labial  wall  of  the  cavity  broken. 
The  fractures  of  this  wall  are  of  various  forms,  and 
in  extent  corresponding  with  the  amount  of  decay 
and  the  friability  of  the  enamel.  There  is  sometimes 
the  triangular  notch,  extending  far  toward  the  middle 
of  the  tooth ;  and  sometimes  there  are  two  or  three 
small  notches ;  and  still  in  other  cases,  almost  the 
whole  of  the  wall  will  be  broken  away  from  the  point 
to  the  neck  of  the  tooth.  When  there  is  simply  a 
notch  in  the  enamel,  it  is  important  for  the  appear- 
ance of  the  tooth  to  fill  it  up ;  and  when  there  is  any 
prospect  of  success,  the  remaining  portion  of  the  wall 
being  retained,  the  operation  is  to  be  performed  as 
already  described  for  the  palatal  wall.  It  will,  how- 
ever, in  many  cases,  be  necessary  to  cut  away  part 
of  the  remaining  portions  of  the  wall,  leaving  the 


FILLING    BY   CLASSES   AND    MODIFICATIONS.  253 

general  form  of  the  border  somewhat  circular,  though 
the  notch  form,  in  some  instances,  is  not  wholly 
obliterated. 

In  filling  this  kind  of  cavity,  it  is  desirable  to  re- 
store as  much  as  possible  the  form  of  the  tooth.  The 
filling  should  be  built  out  from  the  border  of  the  wall 
almost  to  a  line  with  the  tooth's  original  proportions, 
so  that  the  whole  surface  of  the  filling  will  be  con- 
vex ;  and  it  should  be  finished  with  great  care,  the 
Scotch  stone,  buff,  or  stipple  finish  being  preferable 
for  that  part  exposed  to  view. 

?>d  Mod. — The  cavity  extending  almost  to  the  point 
of  the  tooth,  and  terminating  or  running  out  at  the 
surfoce.  In  the  preparation  of  this  cavity,  that  part 
next  the  point  of  the  tooth  should  be  cut  in  enough 
to  form  a  definite  wall  there,  and  to  give  room  for 
sufficient  thickness  and  strength  in  that  portion  of 
the  plug.  Many  operators  attempt  to  fill  this  kind 
of  cavity  without  such  precaution,  terminating  that 
part  of  the  plug  in  a  thin  edge.  This  method  is  very 
objectionable,  for  the  thin  edge  will  become  more  or 
less  separated  from  the  tooth,  and  foreign  substances 
will  be  forced  under  it,  and,  becoming  vitiated,  induce 
decny.  Indeed,  a  defect  of  this  kind  is  a  sure  pre- 
cursor of  the  destruction  of  the  filling.  The  intro- 
duction and  finish  of  the  filling  in  this  kind  of  cavity 
are  the  same  as  first  described  for  this  class ;  and  the 


254  CLASSIFICATION    OF    DECAYED    CAVITIES. 

admonition  may  be  repented  that  there  be  left  no 
thin  overlappings  of  the  filling  that  may  become 
changed  in  position. 

Aith  Mod. — The  cavity  large,  and  the  lateral  walls 
thin  and  friable.  In  this  kind  of  cavity  the  dentine 
is  almost  entirely  removed  from  the  lateral  walls, 
leaving  little  else  than  the  enamel  after  the  excava- 
tion of  the  decay.  These  walls  will  of  course  admit 
of  no  cutting  for  the  purpose  of  giving  them  a  more 
desirable  form.  The  cervical  wall  must  be  shaped 
with  special  reference  to  a  retention  of  the  filling,  to 
consolidate  which  the  requisite  pressure  must  be  ap- 
plied almost  exclusively  toward  this  wall.  It  requires 
extreme  care  to  condense  the  gold  in  cavities  of  this 
kind,  and  adapt  it  to  the  lateral  walls  without  frac- 
turing them ;  various  methods  have  been  suggested 
to  prevent  such  an  accident.  Pluggers  with  very  fine 
points  are  recommended,  as  consolidating  the  gold 
with  much  less  pressure  than  would  be  necessary 
with  large-pointed  instruments.  But  it  has  been 
maintained  that  a  perfect  adaptation  of  the  gold  to 
the  inner  parts  of  these  walls  is  not  important,  pro- 
vided the  adaptation  at  the  border  is  perfect.  It  is 
certain,  however,  that  a  filling  thus  imperfectly 
adapted  is  not  so  good  as  though  the  gold  were  in 
contact  with  all  points  of  the  cavity;  and  besides, 
the  liability  of  fracturing  the  wall  is  just  as  great  in 


FILLING   BY   CLASSES   AND   MODIFICATIONS.  255 

consolidating  at  the  border  as  within.  The  walls  may 
he  sustained  by  enveloping  the  tooth  to  the  borders 
of  the  cavity  with  some  material  perfectly  adaptable 
to  it,  and  capable  of  resisting  the  force  applied  in  the 
process  of  consolidation,  as  gutta-percha  or  plaster  of 
Paris.  If  the  former  is  employed,  it  should  be  soft- 
ened by  warming,  moulded  upon  the  tooth,  and  then 
permitted  to  harden.  The  hardening  may  be  facili- 
tated by  throwing  cold  water  on  it  from  a  syringe. 
It  is  then  to  be  trimmed  even  with  the  border  of  the 
cavity,  so  as  to  admit  the  filling.  If  plaster  of  Paris 
is  to  be  used,  it  should  be  of  the  best  quality.  Yet 
gutta-percha  is  to  be  preferred.  But  a  better  protec- 
tion than  either  may  be  made  of  fusible  metal,  taking 
an  impression  of  the  tooth,  and  from  that  moulding 
the  shield.  In  these  fillings,  when  the  enamel  is 
clear  and  translucent,  the  gold  will  be  visible  through 
it.  To  obviate  this  difficulty,  and  give  strength  to 
the  frail  walls  after  the  cavity  is  formed  and  thor- 
oughly cleansed,  it  should  be  filled  with  oxy-chloride 
of  zinc.  Great  care  must  be  exercised  in  introducing 
this,  to  secure  its  perfect  adaptation  to  every  part  of 
the  cavity ;  and  after  hardening  has  taken  place, 
excavate  as  may  be  requisite,  leaving  enough  to  con- 
stitute a  good  lining  and  support  to  the  thin  walls, 
and  obscure  the  view  of  the  gold. 

The  natural  color  of  the  tooth  may  be  in  this  way 


256  CLASSIFICATION   OF   DECAYED    CAVITIES. 

SO  well  restored  and  maintained  as  to  elude  detec- 
tion ;  at  the  border  of  the  orifice  the  gold  should 
come  in  contact  with  the  dentine  or  enamel.  In 
almost  all  cases  of  thin  weak  borders,  the  gold  should 
be  built  on  and  over  them,  so  as  to  form  a  shield  or 
protection  against  fracture  or  undue  wear.  All  such 
overlapping  portions  should  be  made  so  thick  and 
firm  as  not  to  be  displaced  or  moved. 

The  loss  of  a  portion  of  the  cutting  edge  of  the  in- 
cisors by  extensive  decay  is  often  met  with.  In  all 
such  cases,  when  the  dentine  is  of  good  structure,  it 
is  practicable  to  restore  the  lost  part  to  a  greater  or 
less  extent  by  building  up  with  gold.  In  order  to 
make  successful  operations  in  such  cases,  several 
points  must  be  regarded.  The  dentine  and  enamel 
should  be  of  good  structure ;  the  cavity  toward  the 
neck  of  the  tooth  of  such  a  form  as  to  afford  the  best 
anchorage  ;  this  may  consist  of  pits  with  grooves 
running  out  from  them.  Teeth  with  thick  short 
crowns  present  the  best  opportunity  for  such  an  ope- 
ration ;  indeed,  upon  that  class  of  incisors  with  long 
thiu  crowns,  such  an  operation  is  not  usually  practic- 
able, and  generally  these  teeth  present  such  a  ^con- 
trast in  color  with  the  gold  as  to  be  quite  objection- 
able. In  the  operation  the  manipulation  must  be 
such  as  to  secure  the  most  thorough  welding  of  the^ 
portions  of  gold  of  which  the   filling  is   composed. 


FILLING    BY   CLASSES    AND    MODIFICATIONS.  257 

With  good  attachments,  gold  well  prepared  and  in 
good  condition,  and  properly  manipulated,  the  filling 
may  be  built  up  to  any  desired  extent  without 
danger  of  being  either  drawn  out  or  broken  down. 
The  finish  should  be  such  as  has  already  been 
described  for  fillings  exposed  to  view. 

Fifth  Class. — Posterior  proximal  cavities  of  the 
molars  and  bicuspids.  These  are  separated  like  ante- 
rior proximal  cavities,  except  that,  ordinarily,  to  open 
them  up,  more  is  to  be  cut  from  the  tooth,  on  account 
of  the  greater  difficulty  of  approaching,  inspecting 
and  operating  in  the  cavity.  The  same  general  prin- 
ciples are  applicable  to  the  opening  of  this  class  of 
cavities  as  to  that  of  the  third  class,  except  that 
pressure  for  separating  cannot  be  as  frequently  em- 
ployed, since  the  cavity  will  not  be  as  well  exposed 
by  this  as  by  cutting,  nor  rendered  so  easy  of  ap- 
proach. Indeed,  in  operating  on  these  cavities,  the 
use  of  the  mirror  is  often  necessary,  it  being  im- 
possible to  obtain  a  direct  view  into  them  after 
having  cut  away  all  that  it  is  admissible  to  re- 
move. This  difficulty  is  almost  wholly  obviated 
by  the  method  of  working  through  the  masticating 
surface  of  the  tooth  into  the  cavity  of  decay,  as 
already  described.  The  accessibility  of  these  cavi- 
ties will  depend  on  circumstances,  such  as  the  loca- 
tion of  the  tooth,   its    inclination,   the  size  of  the 


258  CLASSIFICATION    OF    DECAYED    CAVITIES. 

mouth,  the  flexibility  of  the  muscles,  and  the  ability 
of  the  patient  to  open  the  mouth,  and  keep  it  open. 
Generally,  in  operating  on  these  cavities  for  the  re- 
moval of  decay,  for  the  formation  and  the  filling, 
curved  instruments  will  be  required,  but  their  curva- 
ture should  not  be  greater  than  the  necessity  of  the 
case  demands. 

The  cavity,  during  its  preparation,  must  be  fre- 
quently examined.  Its  general  form,  and  the  size, 
kind,  and  location  of  the  retaining-points,  will  be  the 
same  as  in  class  third.  The  lateral  walls,  if  the  cavity 
is  not  too  large,  should  be  made  parallel  with  each 
other;  the  undercutting  at  the  crown  wall  will  be  less 
than  in  anterior  proximal  cavities ;  and  the  cervical 
wall  should  have  a  slightly  inward  inclination — the 
reverse  of  the  same  wall  in  anterior  proximal  cavities. 
In  this  latter  there  should  be  made,  at  different 
angles,  pits  for  retaining-points — three  if  the  tooth 
is  a  molar,  and  two  if  a  bicuspid.  For  making  these 
pits,  the  engine  right-angle  hand-piece  will  be  found 
applicable  and  convenient.  • 

Preparatory  to  introducing  the  filling,  the  same 
appliances  should  be  used  to  protect  the  cavity  from 
moisture  that  have  been  described  elsewhere.  Great 
care  should  be  exercised  in  introducing  and  securing 
the  first  portions  of  gold.  The  size,  form  and  loca- 
tion   of  the   anchorage   points    should    be  carefully 


FILLING    BY    CLASSES   AND    MODIFICATIONS.  259 

noted,  and  into  these  the  filling  should  be  very  per- 
fectly introduced ;  here  the  most  thorough  welding 
of  the  gold  should  be  made,  so  that  each  piece  when 
adjusted  will  be  immovably  fixed.  The  gold  extend- 
ing from  one  anchorage  to  another  constitutes  the 
foundation  upon  which  the  subsequent  part  of  the 
filling  is  to  be  built.  This  may  proceed  uniformly 
from  the  cervical  part  of  the  cavity  to  the  masticat- 
ing surface  of  the  crown,  if,  as  is  usual,  the  prepared 
cavity  involves  this  surface. 

When  the  separation  made  between  the  teeth  con- 
stitutes a  V-shaped  space,  the  filling  should  have  a 
single  plain  or  slightly  convex  surface,  which  will  be 
at  a  greater  or  less  angle  with  the  axis  of  the  tooth 
according  to  the  greater  or  less  amount  cut  away  in 
the  separation.  Much  care  is  requisite  in  order  to 
make  perfect  work  along  the  borders  of  the  lateral 
walls  of  the  cavity ;  these  should  be  secured  as  the 
work  progresses,  and  should  in  no  case  be  left  to 
receive  attention  after  the  body  of  the  filling  is  intro- 
duced. 

When  the  lateral  walls  have  been  cut  away,  as  was 
formerly  the  practice,  it  is  much  more  difficult  to  re- 
store the  crown  to  its  original  form  and  size  than  by 
the  method  now  pursued — retaining  the  lateral  walls 
and  filling  flush  with  them,  and  also  protecting  the 
edges  by  the  filling. 


260  CLASSIFICATION    OF    DECAYED    CAVITIES. 

It  is  claimed  that  the  difficulty  of  filling  this  class 
of  cavities  is  much  diminished  by  the  use  of  the 
matrix.  This  appliance,  in  its  present  form,  is  the 
device  of  Dr.  Lewis  Jack.  He  gives  the  following 
description  of  it  and  its  use  : — '"  These  little  affairs 
are  made  of  a  variety  of  shapes,  sizes,  and  thick- 
nesses. They  are  formed  of  slightly  wedge-shaped 
pieces  of  steel,  and  are,  as  the  cut  designates,  hol- 
lowed out  at  their  thicker  edge,  which  depression 
terminates  at  the  thinner  edge.  At  the  part  of  the 
depression  designed  to  give  shape  to  the  buccal  edge 
of  the  filling,  the  cut  is  generally  abrupt  and  deep ; 
at  the  inner  portion  it  is  more  shallow  and  more  in- 
clined. It  will  be  observed  that  the  depression 
widens  as  it  passes  toward  the  thinner  edge,  to  follow 
the  usual  form  of  proximal  cavities.  The  lower  and 
thin  edge. is  rounded,  to  outline  the  curved  margin  of 
the  cervical  walls,  and  to  effect  pressure  upon  either 
the  gum  or  the  appliances  used  to  stop  the  escape  of 
mucus  and  blood  from  this  tissue. 

"  The  plain  parts  of  the  face  are  file-cut,  or  coarsely 
draw-filed.  The  reverse  side  is  in  most  cases  plain 
and  smooth,  excepting  a  small  portion  at  the  thin 
edge,  which  is  file-cut.  ...  At  each  end  a  square 
cut  is  made,  that  the  ends  of  the  plier  for  adjusting 
them  will  fit  into.  .  .  .  Quite  a  number  of  pairs 
are  necessary  to  meet  the  requirements  of  the  differ- 


FILLING    BY   CLASSES    AND    MODIFICATIONS. 


261 


Fig.  88. 


ing  cases ;  but  for  the  ordinary-sized  simple  proximal 
cavities,  a  dozen  pairs,  varying  in  width,  in  thickness 
and  in  size  of  depression,  are  all  that  I  have  found 
necessary.  ...  The 
character  of  the  modifi- 
cations that  should  be 
made  in  these  will  de- 
pend somewhat  upon 
the  desired  end,  since 
either  a  flat,  contour,  or 
excessively  convex  sur- 
face may  be  produced 
at  the  pleasure  of  the 
operator,  or  to  suit  the 
needs  of  the  individual 
operation,  by  varying 
the  form  and  depth  of 
the  depression." 

The  ordinary  forms 
of  these  appliances  are 
represented  by  Figure 
88. 

Some    additional    de- 
scription of  the  matrices, 
and  the  method  of  using  them,  will  be  given  in  the 
Appendix,  Sec.  D. 

A  piece  of  polished  metal,  of  the  proper  thickness. 


262 


CLASSIFICATION   OF    DECAYED    CAVITIES. 


may  be  placed  back  of  the  cavity  against  the  adjoining 
tooth,  introducing  the  filling,  and  consolidating  it 
firmly  up  to  this  piece  of  metal.  The  lost  portion 
of  the  crown  being  thus  restored,  the  metal  is  then 
removed,  and  the  filling  dressed  oif  and  finished  in 
the  manner  described  heretofore. 

But  when  the  opening  is  made  by  cutting  in  from 
the  masticating  surface,  the  entire  opening  made  in 
the  tooth,  both  by  the  decay  and  the  operation,  will 
be  completely  filled,  and  the  form  of  the  tooth  en- 
tirely restored ;  the  filling  will  then  present  a  proxi- 
mal and  crown  surface.  When  the  teeth,  molars  and 
bicuspids,  are  decayed  upon  their  contiguous  sides, 
the  cavities  in  both  may  be  prepared  as  already  de- 
scribed ;  the  proper  separation  and  excavation  having 
been  made,  both  may  be  filled  together,  the  gold  ex- 
tending across  the  space,  and  after  being  filled  up 
flush  with  the  masticating  surfaces,  the  separation  is 
effected  by  dividing  the  gold  with  a  separating  file. 
Thus,  each  cavity  is  completely  filled,  and  there  is 
always  gold  enough  upon  the  proximal  parts  to 
secure  a  complete  finish.  This  method  is  not  always 
practicable,  as,  for  instance,  when  there  is  a  large 
space,  or  when  it  is  not  desirable  to  fully  restore  the 
form  of  each  tooth ;  but  occasionally  it  may  be  used 
with  advantage.  The  labor,  tedium,  and  difficulty  of 
manipulation  are  increased  the  farther  back  in  the 


FILLING   BY   CLASSES    AND    MODIFICATIONS.  2G3 

mouth  the  decay  is  situated.  The  modifications  of 
this  class  are  the  same  as  those  of  the  third  class  of 
cavities,  and,  except  the  second  modification,  are  sus- 
ceptible of  the  same  methods  of  filling. 

Special  Cases. — The  first  case  that  we  shall  con- 
sider here,  consists  in  a  complication  of  proximal 
decay  with  decay  on  the  buccal  or  palatal  portion  of 
the  tooth,  thus  undercutting  one  of  the  crown  angles. 
Sometimes  these  decays  are  on  both  sides,  in  the 
form  of  transverse  grooves,  meeting  at  the  corner  of 
the  tooth.  In  such  cases,  if  the  pendent  crown 
angle  of  the  tooth  is  firm  and  strong,  the  cavities 
may  be  formed  in  the  proper  manner,  and  filled  with- 
out interfering  with  the  masticating  portion  of  the 
tooth  at  all ;  but  if  the  pendent  portion  is  friable,  it 
should  be  cut  away,  and  the  corner  built  up  with 
gold.  The  method  of  forming  the  part  to  be  filled 
will  depend  on  the  extent  of  the  decay.  When  this 
is  large,  a  greater  number  of  retaining-points  will  be 
required  than  when  it  is  small ;  and  these  should  be 
located  it  such  parts  as  will  make  them  most  tena- 
cious of  the  gold,  and  best  conserve  the  strength  of 
the  tooth.  The  filling  jmay  be  built  up  so  as  to 
restore  the  original  form  of  the  tooth,  thus  presenting 
three  surfaces,  the  proximal,  the  buccal  or  palatal, 
and  the  masticatory ;  or,  it  may  be  made  with  a 
single  slightly  convex  surface,  adapted  and  finished 


264  CLASSIFICATION    OF   DECAYED    CAVITIES. 

most  completely  at  all  its  borders.  This  kind  of 
filling  can  be  made  only  with  cohesive  gold. 

The  palatal  portion  of  the  crown  broken  away,  leav- 
ing the  outer  portion  standing — pulp  not  exposed. — The 
tooth  in  such  case  is  decayed  away,  so  that  the  floor 
of  solid  dentine  is  near  the  margin  of  the  gum,  the 
labial  third  of  the  crown  still  standing.  The  decay 
having  been  all  removed,  four  or  five  little  pits 
should  be  made  on  this  floor,  as  near  its  circumfer- 
ence as  practicable ;  and  a  small  groove  may  be  cut 
from  one  of  these  pits  to  another  all  round  near  the 
edge  of  the  floor.  Then  two  little  pits  should  be 
made  at  the  base  of  the  standing  j)ortion  of  the 
crown,  if  practicable,  without  interfering  with  the 
pulp,  provided  it  is  still  living.  The  tooth  thus  pre- 
pared and  properly  protected  by  the  use  of  the  rub- 
ber dam,  the  filling  may  proceed. 

For  building  up  a  crown  of  this  kind,  only  cohesive 
gold  can  be  used ;  and  this  should  be  of  the  best  pre- 
paration, and  in  the  most  perfect  condition,  since  it 
is  important  that  the  diff'erent  portions  of  the  filling 
be  most  thoroughly  united.  The  instruments  em- 
ployed ill  the  operation  should  be  of  the  best  kind 
and  in  the  best  condition,  the  serrate  points  being 
definite  and  sharp,  though  not  too  lung ;  those  with 
four,  six,  or  eight  points  may  be  advantageously  used 
for  packing  the  gold.     But  care  must  be  exercised 


\ 


FILLING    BY    CLASSES    AND    MODIFICATIONS.  265 

lest  these  fine  points  be  turned ;  for  when  that  is  the 
case,  the  instrument  is  liable  to  displace  the  portion 
of  gold,  and  thus  break  up  its  first  attachment  during 
the  process  of  consolidation ;  and  when  this  is  broken, 
the  piece  of  gold  cannot  again  be  made  to  adhere  as 
perfectly  as  before. 

With  everything  thus  in  readiness,  the  retaining- 
points  are  to  be  all  filled,  the  gold  extending  from 
one  to  the  other ;  this  is  then  to  be  built  all  over 
the  bottom  of  the  part  to  be  restored,  projecting  a 
little  beyond  the  periphery,  and  being  perfectly  con- 
solidated there,  and  kept  somewhat  higher  round  the 
border  than  in  the  centre.  The  gold  should  be  built 
up  in  this  manner  till  the  crown  is  large  enough, 
after  dressing,  to  give  the  desired  size  and  form.  In 
finishing  up,  the  aim  should  be  to  restore  as  perfectly 
as  possible  the  lost  form  of  the  tooth.  The  adapta- 
tion of  the  gold,  too,  to  the  standing  portion  of  the 
crown  should  be  most  complete  ;  imperfection  in  this 
respect  impairs  the  appearance  of  the  work,  and 
jeopardizes  the  security  of  the  operation. 

Occasionally  the  crown  of  a  molar  tooth  is  found 
decayed  off  all  round,  almost  to  the  margin  of  the 
gum,  the  pulp  having  previously  receded  so  as  not 
to  be  exposed.  It  is  in  such  case  desirable  to  re- 
store the  lost  portion  of  the  crown,  and  make  a  mas- 
ticating surface  such  as    shall  antagonize   properly 


266  CLASSIFICATION    OF   DECAYED    CAVITIES, 

with  the  teeth  of  the  opposite  jaw.  As  yet,  there  is 
no  other  method  of  accomplishing  this  than  by  build- 
ing it  up  with  gold — cohesive  gold  foil,  or  crystal 
gold.  In  the  preparation  for  this  crown  of  gold,  the 
edge  should  be  dressed  smooth  and  even  all  round 
the  tooth ;  then  six  or  eight  deep  pits  should  be 
made  at  different  angles  on  the  base  thus  pre- 
pared ;  and  they  should  be  bored  with  a  drill  larger 
than  is  commonly  used  for  retaining-points.  These 
pits  may  be  slightly  enlarged  within.  The  method 
of  building  up  the  crown  is  just  the  same  as  that  de- 
scribed for  building  up  part  of  a  crown,  the  pits  being 
first  filled,  then  joined  together,  and  the  gold  ex- 
tended all  over  the  part  to  be  cavered  by  the  filling. 
In  extending  the  gold  from  a  retaining-point  or 
points,  it  is  necessary  to  build  up  to  a  considerable 
thickness  above  the  orifice  of  the  pit.  The  portion 
of  gold  extending  along  on  the  tooth  from  the  pit 
should  be  quite  thick  and  firm,  so  as  not  to  curl  up 
from  its  position,  on  the  addition  of  subsequent  por- 
tions. Every  particle  of  gold,  indeed,  should  be  so 
manipulated,  that  it  will  securely  maintain  its  first 
position.  The  permanency  of  the  operation  will  depend 
very  much  upon  this  precaution.  The  gold  should  ex- 
tend somewhat  beyond  the  circumference  of  the  tooth 
all  around,  in  order  to  a  thorough  adaptation  and  finish. 
The  foundation  thus  prepared,  and  kept  free  from 


FILLING    BY   CLASSES    AND    MODIFICATIONS.  267 

moisture,  the  crown  is  easily  built  up  by  the  ordinary 
method  of  packing  the  gold.  Any  desired  shape  can 
be  given  to  this  artificial  crown ;  but,  of  course,  that 
which  most  nearly  resembles  the  form  of  the  natural 
crown  is  in  all  cases  to  be  desired.  The  masticating 
surface  of  this  gold  crown  is  to  be  formed  from  the 
indications  given  by  the  antagonizing  teeth.  Such 
crowns  will  wear  for  years,  and  perform  all  the  func- 
tions of  the  natural  organs.  Artificial  crowns  of  this 
kind  have  been  attached  to  the  tooth,  by  screwing 
into  the  pits  small  pieces  of  gold  wire  at  different 
angles,  and  then  building  up  round  and  between 
them  with  the  gold  foil,  on  the  principle  already  de- 
scribed, thus  making  these  wires  serve  as  so  many 
anchors  for  fastening  the  work.  The  use  of  screws 
for  securing  fillings  in  these  extreme  cases  was  sug- 
gested, and  perhaps  occasionally  used,  more  than 
twenty  years  ago,  by  Dr.  W.  H.  Dwindle.  But 
during  the  last  four  years  their  practicability  has  been 
more  fully  demonstrated  by  Dr.  Mack,  who  devised 
a  set  of  instruments  by  which  small  gold  screws  can 
be  very  readily  introduced  wherever  they  are  re- 
quired. These  screws,  as  made  by  Dr.  Mack,  are 
screw-cut  the  entire  length,  except  a  small  portion 
of  the  outer  end,  which  is  made  flat  and  wedge- 
shaped;  upon  this  flattened  part  the  screwdriver 
acts  when  the  screw  is  introduced. 


268 


CLASSIFICATION    OF    DECAYED    CAVITIES. 


Something  additional  in  this  direction  seemed  desi- 
rable, and  to  meet  this  want,  Dr.  E.  Osmond,  about 
four  years  ago,  made  an  improved  screw,  and  con- 
structed a  set  of  instruments  for  introducing  it. 
These  are  represented  in  the  following  cut. 


Fig.  89 


These  screws  are  made  of  twenty-carat  gold,  an- 
nealed and  split  about  half-way,  once  or  twice,  so  as 
to  form  two  or  four  arms.  These  are  opened  and 
turned  down,  as  may  be  necessary  after  being  in- 
serted. 

They  are  made  of  different  sizes,  to  meet  the  re- 
quirements of  different  cases,  and  the  instruments  are 
adapted  to  the  different  screws.  The  teeth  repre- 
'  sented  in  this  cut  show  large  converging  cavities,  in 
which  the  screws  are  fixed,  ready  for  the  attachment 
of  the  filling. 

It  has  been  suggested  that  making  barbes  on  the 


FILLING    BY   CLASSES   AND    MODIFICATIONS.  269 

screws  would  give  greater  security  to  the  filling  than 
the  plain  screw,  yet  with  Dr.  Osmond's  screws  the 
utmost  security  is  attained.  Of  course  cohesive  gold 
is  always  to  be  used  with  this  kind  of  anchorage. 

Security  of  attachment  of  these  large  fillings  may 
in  many  cases  be  quite  as  well  attained  with  the 
foil  alone.  But  good  tooth-structure  and  properly- 
located  and  well-formed  anchorages  are  very  im- 
portant. 

Filling  large  cavities  on  the  labial  surfaces  of  the 
superior  incisors. — These  cavities  are  usually  super- 
ficial, and  frequently  co-extensive  with  a  considerable 
part  of  the  surface  of  the  tooth.  A  method  of  filling 
them,  somewhat  novel,  though  not  without  merit,  has 
been  introduced  to  the  notice  of  the  profession  by 
Dr.  Volck,  it  having  been  first  suggested  to  him,  how- 
ever, by  Dr.  Maynard.  It  consists  in  filling  up  the 
cavity  principally  with  a  piece  of  enamel,  as  near  the 
color  of  the  tooth  as  possible.  The  cavity,  when 
nearly  round,  should  be  formed  with  a  wheel  bur  of 
the  proper  size ;  and  after  having  been  thus  reamed 
out,  a  slight  undercutting  should  be  made  all  round 
with  an  excavator.  Then  a  piece  of  enamel  being 
selected,  it  is  dressed  to  a  proper  thickness,  which 
should  be  slightly  greater  than  the  cavity's  depth, 
and  to  a  perfectly  circular  form,  its  size  being  such 
as  to  let  it  drop,  with  a  little  play,  into  the  cavity, 


270  CLASSIFICATION    OF    DECAYED    CAVITIES. 

and  the  edge  of  it  beveled  from  without.  For  fasten- 
ing this  in  the  cavity,  roll  a  strip  of  several  thick- 
nesses of  gold  foil  round  its  edge,  and  add  as  much  as 
can  be  forced  in  with  it.  Thus  prepared,  set  it  in 
place  in  the  cavity,  and  then  condense  the  gold  down 
into  the  groove  all  round  with  a  thin-pointed  plugger, 
more  gold  being  added,  if  necessary,  to  fill  the  groove 
completely  full.  Afterwards,  with  the  file,  stone, 
and  burnisher,  dress  off  the  whole  to  a  proper  level 
with  the  surrounding  tooth,  finishing  very  carefully 
with  the  burnisher.  The  unsightliness  of  a  large 
gold  filling  on  a  front  tooth  is  thus  obviated,  no 
metal  except  that  composing  the  ring  of  attachment 
in  the  groove  being  exposed  to  vi-ew.  It  is  a  beauti- 
ful operation,  and  one  whose  successful  accomplish- 
ment will  require  considerable  constructive  talent 
and  skill. 

A  better  method  of  performing  this  operation,  for 
many  cases,  at  least,  is  by  setting  a  porcelain  filling 
or  block  in  oxy-chloride  of  zinc.  The  cavity  should 
be  prepared  as  usual,  the  borders  neatly  trimmed, 
and  made  as  free  as  possible  from  irregularities. 
Select  a  section  of  a  porcelain  tooth,  as  near  the 
color  and  surface  conformation  of  the  tooth  to  be 
filled  as  possible  j  then  fit  the  piece  to  be  suj^plied 
carefully,  making  it  to  conform  to  the  cavity  as  accu- 
rately as  possible ;  it  should  be  a  little  thinner  than 


I 


FILLING    BY   CLASSES    AND    MODIFICATIONS.  271 

the  depth  of  the  cavity.  The  cavity  now  being 
secured  against  moisture,  and  made  perfectly  dry, 
oxy-chloride  of  zinc,  or  better,  perhaps,  Guilloi's 
cement,  because  it  hardens  less  rapidly,  should  be 
prepared  of  such  a  consistence  as  to  permit  the  accu- 
rate adjustment  of  the  porcelain  filling.  This,  after 
being  put  in  place,  should  not  be  disturbed  nor  moist- 
ened till  the  cement  is  well  set.  It  is  better  to  cover 
the  joint  with  wax  or  varnish,  and  let  it  remain  a 
day  or  two  before  attempting  to  dress  or  polish  the 
porcelain ;  if,  however,  the  work  has  been  perfectly 
done,  nothing  else  will  be  required. 

An  operation  performed  in  this  manner  is  prefer- 
able to  a  filling  of  gold  for  this  class  of  cavities  ;  it  is 
less  apparent  to  the  view ;  indeed,  when  a  proper 
selection  has  been  made,  and  the  adaptation  is  good, 
it  will  not  be  visible  at  all  except  under  the  closest 
observation ;  and  usually  the  tooth  will  be  as  well 
protected,  and  in  many  instances  better,  than  by  the 
common  method  of  filling. 

The  use  of  platinum  and  gold  foil  together,  as 
suggested  by  Dr.  Black,  for  filling  these  cavities,  is 
better  than  gold,  so  far  as  appearance  is  concerned ; 
the  striking  contrast  between  the  color  of  the  gold 
alone  and  that  of  the  tooth  is  materially  relieved. 


CHAPTEU  VIIL 

PATHOLOGICAL   CONDITIONS. 

Hitherto,  in  the  consideration  of  the  treatment  of 
caries,  the  subject  of  the  vitality  and  pathological 
conditions  of  the  teeth  has  been  intentionally  omitted. 
It  now  remains  to  describe  the  diseased  conditions  to 
which  the  teeth  are  subject,  and  the  treatment  which 
those  respective  conditions  indicate.  This  is  an  im- 
portant department  of  the  practice,  since  upon  skill 
in  this,  as  well  as  upon  the  manner  of  performing  the 
work,  the  success  of  the  operation  depends. 

Premising  that  our  remarks  on  this  branch  of  the 
subject  are  predicated  on  the  fact  admitted,  that  the 
teeth  possess  vitality,  we  proceed  to  consider  the 
pathological  conditions  to  which,  in  common  with  all 
vital  tissues,  they  are  liable.  There  is  but  one  diseased 
condition  of  living  dentine,  anterior  to  decay,  that 
presents  any  considerable  difficulty  in  the  ordinary 
operation  of  filling  teeth,  and  that  is,  inflammation, 
or  exalted  sensibility.  This  condition  was  referred 
to  in  the  remarks  on  the  treatment  of  caries,  as  being 
one  that  most  generally  accompanies  decay  of  the 


SENSITIVE    DENTINE.  273 

teeth.  Whether  or  not  this  affection  is  real  inflam- 
mation, is  a  point  that  has  been  considerably  contro- 
verted ;  and  the  assertion  has  been  made  that  it  is  of 
no  consequence  whether  it  is  or  not,  provided  we 
understand  the  true  method  of  treating  it.  This, 
however,  is  not  to  be  so  readily  conceded ;  for  the 
confession  that  we  do  not  know  what  to  call  a  thing, 
generally  implies  an  ignorance  of  its  character  and 
phenomena.  While  the  term  inflammation  conveys  a 
more  definite  notion,  the  phrase  exalted  sensihiliti/  is 
very  vague  in  meaning.  That  it  is  true  inflammation, 
is  the  opinion  of  our  best  dental  writers. 

The  dentine  is  endowed  with  the  functions  of  ab- 
sorption, nutrition,  and  secretion,  modified  somewhat 
by  the  peculiarity  of  the  structure — characteristics 
that  always  imply  a  susceptibility  of  inflammation. 
In  inflammation  of  the  soft  parts  there  are  present 
various  indications, — as,  pain,  redness,  swelling,  and 
increased  heat.  But  in  dentine,  on  account  of  its 
peculiar  structure,  all  these  indications  cannot  be 
manifested :  for  instance,  redness,  since  the  red  glob- 
ules do  not  circulate  through  it ;  nor  swelling,  since 
the  structure  is  dense — devoid  of  mobility ;  nor  per- 
ceptibly increased  heat,  since  the  circulation  is  of  too 
low  a  grade.  But  one  of  the  most  definite  indications 
of  inflammation,  namely,  exalted  sensibility,  is  pre- 
sent here  in  a  very  marked  degree;  and  there  are 


274  PATHOLOGICAL   CONDITIONS. 

various  other  circumstances  that  indicate  this  condi- 
tion to  be  real  inflammation :  the  same  irritating 
causes  that  induce  inflammation  in  the  more  highly 
organized  parts,  occasion  it  in  the  living  dentine. 
This  condition  of  the  teeth  is  always  affected  by  a 
general  inflammatory  diathesis,  and  their  sensitive- 
ness, when  there  is  this  general  tendency  to  inflam- 
mation, is  always  increased,  and  local  treatment  in 
such  case  will  commonly  be  inefficient ;  a  modifica- 
tion of  such  a  condition  of  the  S3'stem  produces  a 
corresponding  change  in  the  affected  teeth ;  and  those 
remedial  agents  which  are  employed  in  the  topical 
treatment  of  inflammation  elsewhere  are  successfully 
used  in  the  treatment  of  inflamed  dentine.  From  all 
these  circumstances  we  infer  that  this  affection  of  the 
teeth  is  a  real  inflammation. 

As  has  been  already  remarked,  the  only  definite 
and  direct  indication  of  inflammation  of  the  dentine 
is  exalted  sensibility,  though  this  is  not  an  immediate 
consequence  of  that  condition,  independent  of  exter- 
nal circumstances ;  for  the  pain  resulting  directly 
from  inflammation  in  the  soft  parts  is  not  experienced 
here,  by  reason  of  the  low  grade  of  vitality  and  the 
feeble  circulation.  But  the  teeth  in  a  state  of  inflam- 
mation will  suffer  pain  when  subjected  to  sudden 
variations  of  temperature,  whether  induced  by  the 
air,  by  fluids,  or  b}'  contact  with  any  hard  substance ; 


SENSITIVE   DENTINE.  275 

and  when  subjected  to  the  influence  of  agents  that 
irritate  the  nerve-tissue  anywhere,  such  as  acids, 
some  alkalies,  salts,  &c.  In  regard  to  degree,  extent, 
and  location,  this  affection  exhibits  a  variety  of  mani- 
festations ;  in  degree,  from  the  most  mild  to  the  most 
intense — sometimes  fixed  at  a  uniform  pitch  of  pain, 
and  sometimes  passing  through  the  gamut  of  torture 
up  to  the  most  acute  anguish.  The  character  of  the 
affection  is  modified  by  differences  in  the  organic 
structure  of  the  teeth,  those  most  vascular  and  most 
highly  organized  being  most  readily  and  most  exten- 
sively involved ;  and  therefore  the  teeth  of  the  young 
are  generally  more  liable  to  it  than  those  of  the  old. 
So,  too,  persons  of  a  plethoric  or  a  strumous  habit,  as 
well  as  those  in  a  febrile  condition,  are  peculiarly 
predisposed  to  this  affection.  Sometimes  irritation 
or  disturbance  of  other  organs  of  the  system  sympa- 
thetically or  secondarily  induce  inflammation  of  the 
dentine.  Uterine  irritation  frequently  does  so,  and 
hence,  during  pregnancy,  or  a  protracted  suppression 
of  the  catamenia,  the  teeth  are  very  liable  to  be 
thus  affected,  and,  if  decayed,  to  become  very  sensi- 
tive. 

Inflammation  of  the  dentine  will  sometimes  be 
exhibited  in  various  degrees  in  different  teeth  in  the 
same  mouth  at  one  time.  This  is  owing  to  differ- 
ences in  the  organic  structure  of  teeth  developed  at 


276  PATHOLOGICAL    CONDITIONS. 

different  periods  of  life,  to  differences  of  their  loca- 
tion in  the  mouth,  and  to  differences  of  exposure  to 
those  agencies  which  are  apt  to  induce  the  condition. 
As  to  the  extent  of  this  inflammation,  it  may  be  con- 
fined to  a  thin  lamina  of  bone  immediately  beneath 
the  decomposed  portion,  or  may  extend  deep  into  the 
body  of  the  tooth,  and,  indeed,  in  some  cases,  pervade 
the  dentine  of  the  entire  crown.  This  latter  extent, 
however,  is  not  likely  to  occur,  unless  there  is  a  gen- 
eral predisposition :  if  it  is  produced  by  local  causes, 
it  will  not,  in  general,  penetrate  very  deeply  into  the 
dentine.  Most  commonly,  the  greatest  sensitiveness 
is  at  the  union  of  the  dentine  with  the  enamel ;  but 
sometimes  it  is  confined  to  a  small  point  within  the 
cavity,  either  because  there  is  a  concentration  of 
nerve-fibrils  there,  or  because  there  has  been  a 
determination  of  the  irritating  influences  to  that 
point — the  former  being  probably  the  more  frequent. 
The  greatest  sensitiveness,  as  already  remarked,  is 
generally  at  the  surface  of  the  dentine,  because  that 
is  the  termination  of  the  nerve-fibrils  which  ramify 
the  dentine,  and  wherever  nerve-fibre  terminates, 
there  always  we  may  look  for  exalted  sensibility. 
Hence  it  is  that  decay  of  the  teeth  is  often  found  to 
be  more  sensitive  in  its  incipient  stages  than  when 
it  has  become  more  advanced. 

Treatment  of  Inflamed  Dentine. — There  are  several 


I 


TREATMENT   OF    SENSITIVE    DENTINE.  277 

methods  of  treatment  that  may  be  employed  to 
remedy  this  condition.  In  many  cases,  where  time 
and  circumstances  will  permit,  a  removal  of  all  irri- 
tating agents  from  the  affected  parts  will  enable 
nature  to  effect  a  restoration  to  health.  All  decom- 
posed dentine  is  to  be  removed  from  the  cavity, 
every  exciting  influence  in  it  withdrawn  or  neutral- 
ized, and  the  cavity  itself  perfectly  filled  with  some 
non-conducting  material,  so  as  entirely  to  exclude  all 
foreign  substances.  So  far  as  non-conduction  of  heat 
is  concerned,  there  is  perhaps  nothing  better  than 
"  Hill's  stopping ;"  or  in  some  cases  tin  or  gold  may 
be  used ;  but  when  either  of  these  is  employed  for 
this  treatment,  some  non-conducting  substance  should 
be  placed  between  the  filling  and  the  sensitive  den- 
tine. The  length  of  time  necessary  for  the  restora- 
tion of  the  affected  part,  under  this  treatment,  will 
be  much  varied  by  circumstances.  The  cases  sus- 
ceptible of  this  kind  of  treatment  are  those  in  which 
there  is  no  constitutional  predisposition,  in  which  the 
vitality  is  strong,  and  the  recuperative  power  vigor- 
ous. When  the  temporary  fillings  are  made  of 
metals,  the  patient  should  be  careful  to  protect  them 
from  sudden  changes  of  temperature.  For  such 
fillings,  in  case  they  are  required  but  for  a  short 
time,  a  lock  of  cotton  saturated  with  a  solution  of 
gutta-percha  and  chloroform  may  be  used. 


278  PATHOLOGICAL   CONDITIONS. 

But  in  cases  in  which  the  vitality  is  low,  the 
affection  chronic,  the  exciting  cause  highly  irritating, 
and  the  general  diathesis  inflammatory,  nature,  un- 
aided, will  not  affect  a  cure.  In  such  circumstances, 
therapeutic  treatment  is  indicated.  The  agents  em- 
ployed in  topical  treatment  may  be  divided  into  two 
classes :  first,  resolvents,  or  those  which  have  for 
their  object  an  entire  restoration  to  health  of  the  part 
affected ;  and  second,  escharotics,  or  those  which 
have  for  their  object  the  death  of  a  portion  or  all  of 
the  diseased  part.  The  former  class  of  agents  is  of 
course  preferable,  when  the  object  can  be  promptly 
accomplished  by  their  use,  and  especially  preferable 
to  those  agents  which  endanger  the  vitality  of  the 
whole  tooth.  In  very  many  cases  in  which  topical 
applications  are  indicated,  constitutional  treatment  is 
also  required ;  and  this  should  be  of  an  antiphlogistic 
character.  The  immediately  adjacent  parts,  too,  as 
the  gums,  the  mucous  membrane,  etc.,  should  be 
carefully  regarded.  Indeed,  treatment  of  the  gums 
by  counter-irritation,  depletion,  and  various  prepara- 
tions, such  as  the  conditions  may  indicate,  will  often 
be  found  pre-requisite  to  a  successful  treatment  of 
sensitive  dentine  by  topical  applications. 

There  are  very  few  agents  used  simply  as  resolv- 
ents. The  properties  characteristic  of  this  class  of 
agents  are  tonic,  stimulant,  sedative,  and  astringent. 


TREATMENT    OF    SENSITIVE    DENTINE.  279 

Capsicum  may  fitly  represent  the  stimulant ;  Peru- 
vian bark,  and  gum  myrrh,  the  tonic;  tannin  the 
astringent;  and  opiates  the  sedative  principle.  As- 
tringents, stimulants,  and  sedatives  all  tend  to  coun- 
teract inflammation.  The  agents  of  this  class  are 
not  very  extensively  used  in  the  treatment  of  den- 
tine, not  because  they  are  not  ultimately  efficient, 
but  because  their  action  is  less  vigorous  than  that  of 
some  other  agents.  When,  however,  time  and  cir- 
cumstances will  permit,  mild  treatment,  if  efficient,  is 
to  be  preferred. 

But  there  are  many  cases  in  which,  for  want  of 
time,  something  more  rapid  in  its  action  is  required. 
Of  this  character  is  the  second  class  of  therapeutic 
agents,  namely,  escharotics,  or  those  which  by  their 
action  destroy  a  portion  of  the  tissue  with  which 
they  come  in  contact.  It  may  be  well  to  notice, 
separately,  the  preparations  commonly  used  for  this 
purpose. 

Tannin,  or  Tannic  Acid. — This  is  the  active  prin- 
ciple of  vegetable  astringents,  and  is  found  most 
abundant  in  nutgalls.  It  unites  with  albumen,  fibrin, 
and  gelatin,  forming  with  them  insoluble  tan  nates. 
Its  medicinal  influence  is  almost  necessarily  topical, 
since  the  promptness  of  its  action  on  albuminous  sub- 
stances, and  the  insolubility  of  its  compounds  with 
them,  prevent  its  admission  into  the  general  circula- 


280  PATHOLOGICAL   CONDITIONS. 

tion.  The  action  of  tannin  on  dentine  has  been 
akeady  explained.  Either  its  aqueous  or  its  alcholic 
solution  may  be  employed,  the  latter  being  the  better 
and  more  convenient  preparation.  It  is  however  re- 
cently used  by  solution  in  creosote  and  glycerin, 
which  constitute  a  very  valuable  preparation.  Where 
tannin  is  applied  to  dentine,  there  is  formed  a  tannate 
of  albumen,  which,  being  insoluble,  protects  from  irri- 
tation, and  probably  incites  to  healthy  condition  the 
living  parts  beneath  it. 

Creosote,  or  Carholic  Acid. — Formerly,  creosote  was 
obtained  by  distillation  of  wood,  and  differed  some- 
what from  that  in  present  use,  which  is  prepared  by 
distillation  of  coal  tar.  It  dissolves  freely  in  alcohol 
or  ether,  and  sparingly  in  water;  its  action  may, 
therefore,  be  modified  by  dilution.  Creosote  produces 
its  caustic  effects  by  its  affinity  for  albumen  and 
gelatin,  with  which  it  forms  insoluble  compounds ; 
and  from  its  modus  operandi,  it  is  evident  that  the 
popular  opinion  that  it  promotes  decay  of  the  teeth 
is  an  error. 

Nitrate  of  Silver. — This  salt  is  a  powerful  caustic, 
whether  applied  to  soft  parts  or  to  bony  tissue.  Its 
action  is  somewhat  complex.  Nitric  acid  is  liberated 
by  the  decomposition  of  the  salt  when  in  contact 
with  organic  matter.  Nitrate  of  silver  has  a  strong 
affinity  for  albumen,  uniting  with  it  without  difficulty; 


TREATMENT    OF    SENSITIVE    DENTINE.  281 

and  the  compound  thus  formed  is  soluble  in  nitric 
acid.  When  the  nitrate  is  applied  to  the  skin,  the 
immediate  result  is  a  whitish  mark  caused  by  a  union 
of  the  salt  with  the  albumen  of  the  cuticle ;  but  this 
soon  turns  black,  by  the  reduction  of  the  salt  and  the 
liberation  of  the  oxide  of  silver,  when  for  each  atom 
of  this  set  free  there  is  liberated  an  equivalent  of 
nitric  acid.  There  is  here,  then,  an  agent  that  acts 
promptly  on  the  gelatinous  portion  of  the  tooth,  de- 
stroying its  vitality  to  the  extent  of  the  combination 
which  takes  place,  and  that,  by  the  decomposition  of 
part  of  the  salt,  and  the  consequent  liberation  of  part 
of  the  acid,  also  acts  with  energy  on  the  calcareous 
portion.  The  compound  formed  by  the  nitrate  with 
the  organic  constituents  of  the  tooth,  is  insoluble  ex- 
cept with  a  few  substances,  and  therefore  protects 
the  subjacent  parts ;  and  the  precipitation  of  the 
reduced  oxide  on  the  surAice,  it  is  claimed,  affords 
some  additional  protection.  The  insolubility  of  the 
compound  above  mentioned  prevents  an  absorption 
of  the  nitrate  by  the  dentine,  and  renders  its  action 
necessarily  superficial.  When  the  nitrate  is  neutral- 
ized by  a  union  with  it  of  an  equivalent  of  the  con- 
stituents of  the  dentine,  no  further  chemical  action  is 
possible.  The  compound  formed  by  this  union  is 
soluble  in  a  dilution  of  the  nitrate ;  and  if  this  be 
ap[)lied  in  too  great  a  quantity,  there  may  be  a  larger 


282  PATHOLOGICAL   CONDITIONS. 

loss  of  substance  than  is  desirable  or  at  all  necessary  ; 
for  as  long  as  free  nitrate  remains  in  solution  in  the 
cavity,  the  insoluble  compound  is  not  precipitated, 
and  the  surface  is  therefore  exposed  to  the  continued 
action.  It  is  preferable  to  employ  the  nitrate  in  the 
solid  state,  or,  when  this  is  not  practicable,  in  a  con- 
centrated solution,  and  small  quantity,  rather  than  in 
a  copious  dilution  and  repeated  application. 

From  the  observations  already  made,  it  is  quite 
evident  that  no  harm  can  result  to  the  tooth  from  a 
proper  application  of  this  agent,  beyond  the  portion 
of  it  immediately  acted  upon.  The  nitrate  cannot  be 
absorbed  by  dentine,  but  it  stimulates  the  subjacent 
dentine  to  more  healthy  action;  though  some  main- 
tain that  it  is  not  as  efficient  in  this  respect  as  some 
proper  chloride.  It  acts  to  a  greater  depth  than 
tannin  or  creosote,  but  not  so  deep  as  chloride  of  zinc, 
nor  with  so  much  pain.  Great  care  should  be  exer- 
cised that  its  contact  be  permitted  no  further  than 
its  action  is  desired. 

Chloride  of  Zinc. — This  agent  has  been  extensively, 
though  much  less  now  than  formerly,  used  in  the 
treatment  of  sensitive  dentine.  It  exerts  an  anti- 
septic and  disinfectant,  as  well  as  an  escharotic,  influ- 
ence. In  its  operation  it  decomposes ;  the  chlorine 
obtaining  hydrogen  by  decomposition  of  water, 
hydrochloric   acid   is  formed ;    this  unites  with  the 


TREATMENT    OF    SENSITIVE    DENTINE.  283 

calcareous  elements,  and  breaks  down  the  animal 
constituent  as  well.  It  is  milder  in  solution  than  in 
solid,  and  less  efficient  and  less  painful.  It  is  soluble 
in  water,  alcohol,  ether,  or  chloroform.  The  etherial 
and  the  chloroformal  solutions  are,  in  their  action, 
least  painful  of  all  the  forms  in  which  this  chloride  is 
applied.  The  union  of  this  agent  with  the  gelatinous 
constituent  of  the  tooth  is  also  more  prompt  in  solu- 
tion than  in  solid.  The  ether  and  the  chloroform  may 
lessen  the  pain  by  their  anaesthetic  influence.  In  the 
use  of  the  chloride,  or  any  other  active  caustic,  it  is 
important  to  bear  in  mind  the  exalted  vitality  which 
follows  its  application ;  and  the  operation  should  be 
immediately  performed.  In  the  teeth  of  young  per- 
sons, or  those  in  which  the  animal  constituent  greatly 
predominates,  the  vitality  will  be  more  promptly 
aroused  than  in  those  of  an  opposite  texture,  and  the 
change,  too,  will  be  greater.  If  the  inflammation  is 
confined  to  a  thin  lamina,  it  will  be  almost  instantly 
allayed  by  the  application  of  the  chloride,  and  the 
cavity  may  be  excavated  as  though  there  had  never 
been  exalted  sensibility  in  it ;  but  if  the  operation  be 
delayed  any  considerable  time,  the  tooth  will  often 
be  found  in  a  worse  condition  for  excavating  than 
before  the  application.  The  remarks  on  absorption 
under  the  head  of  nitrate  of  silver  apply  with  equal 
force  here :  there  is  not  the  least  danger  from  this 


284  PATHOLOGICAL   CONDITIONS. 


source ;  indeed,  there  can  be  none,  even  when  the 
chloride  is  applied  to  the  soft  parts. 

Terchloride  of  Gold. — Of  this  preparation  the  ethe- 
rial  solution  only  has  been  employed.  This  acts 
with  great  promptness  on  the  dentine,  forming  an 
insoluble  compound  with  the  gelatinous  elements, 
and  the  chlorine  performing  its  role  upon  the  calca- 
reous portion.  On  account  of  the  promptness  with 
which  this  agent  operates,  neither  the  pain  nor  the 
disturbance  of  the  subjacent  parts  caused  by  it  is 
great.  This  substance  is  very  liable  to  decomposi- 
tion. B}^  exposure  to  air  or  light,  the  gold  is  pre- 
cipitated in  the  metallic  form.  But  protected  from 
these,  it  may  be  preserved  for  a  long  time.  This 
agent  will  not  be  absorbed  by  the  dentine. 

Arsenious  Acid. — The  modus  operandi  of  this  agent 
is  involved  in  obscurity.  In  regard  to  its  topical 
action.  Professor  Bache  says :  "  Arsenious  acid,  when 
it  produces  the  death  of  a  part,  does  not  act,  strictly 
speaking,  as  an  escharotic ;  it  destroys  the  vitality  of 
the  organized  structure,  and  its  decomposition  is  the 
consequence.  The  true  escharotic  acts  chemically, 
producing  a  decomposition  of  the  part  to  which  it  is 
applied, — a  state  incompatible  with  life."  Pereira 
says :  "  Though  employed  as  a  caustic,  yet  the  nature 
of  its  chemical  influence  on  the  animal  tissue  is  un- 
known ;    hence  it    is   termed    by  some  a  dynamic 


TREATMENT    OF    SENSITIVE    DENTINE.  285 

caustic."  Its  escharotic  power  certainly  bears  no 
proportion  to  its  devitalizing  power;  but  it  is  pro- 
bable that  it  forms  definite  compounds  witb  some  of 
the  constituents  of  living  tissue ;  and  if  so,  these 
compounds  appear  to  be  readily  and  rapidly  decom- 
posed, so  that  the  acid  becomes  again  free  to  attack, 
with  similar  results,  the  subjacent  parts.  The  topical 
application  of  arsenic  is  liable  to  be  followed  by  con- 
stitutional effects. 

All  dentists  are  aware  of  the  fact  that  a  tooth-pulp 
may  be  destroyed  by  arsenic,  through  a  wall  of  con- 
siderable thickness.  To  accomplish  this,  the  agent 
must  in  some  way  penetrate  the  substance  of  the 
dentine,  and  its  vitality  is  destroyed  so  far  as  it  is 
thus  penetrated ;  indeed,  the  vitality  of  the  whole 
crown  of  the  tooth,  both  dentine  and  pulp,  is  often 
destroyed  by  the  use  of  this  remedy,  applied  even 
to  a  small  cavity.  Exalted  sensibility  of  dentine  is 
subdued  by  this  agent,  more  by  its  devitalizing  than 
through  its  chemical  energy.  It  is  soluble  in  creosote 
and  similar  oils,  and  to  a  considerable  extent  in 
alcohol  and  water.  It  is  absorbed  much  more  rapidly 
when  applied  in  solution  than  in  solid ;  and  the  more  ' 
vascular  the  dentine,  the  more  rapid  and  extensive 
will  be  the  absorption ;  and  on  this  account  there  is 
great  risk  in  applying  it  to  the  teeth  of  young  per- 
sons, or  to  any  teeth  that  are  highly  wanting  in  den- 


286  PATHOLOGICAL    CONDITIONS. 

sity;  indeed,  it  will  destroy  the  A'itality  of  A^ery  dense 
teeth.  The  manner  in  which  it  passes  into  the  den- 
tine is  not  very  definitely  understood.  It  is  A^ery 
certain,  however,  that  in  more  highly  organized  parts 
it  is  carried  through  by  the  circulation,  and  also  may 
be  taken  up  by  imbibition.  In  either  of  these  ways 
it  may  pass  into  the  dentine,  and  so  far  as  concerns 
the  results,  it  matters  not  in  Avhich  way.  It  is 
enough  to  know  that  there  are  well-defined  cases  of 
its  specific  effect  on  the  constitution,  after  having 
been  applied  to  dentine,  demonstrating  that  it  must 
have  been  taken  up  by  the  circulation;  and  also  cases 
of  its  manifest  effect  on  the  periosteum  in  a  short 
time  after  having  been  applied  to  the  cavity  of  a 
tooth  the  pulp  of  which  is  dead — thus  proving  that 
it  must  have  been  absorbed  by  imbibition. 

If  arsenic  is  ever  employed  in  the  treatment  of 
sensitive  dentine,  it  should  be  suffered  to  remain  in 
the  cavity  but  a  short  time, — from  one  to  three 
hours, — and  then  the  part  with  which  it  was  in  con- 
tact should  be  very  thoroughly  excavated.  In  decid- 
ing in  what  cases  it  is  jDroper  to  use  it,  there  is  need 
of  careful  discrimination  as  to  the  tooth's  structure 
and  density,  for  injurious  results  have  sometimes 
followed  its  application,  notwithstanding  the  utmost 
care ;  if  it  has  once  been  absorbed  by  the  dentine, 
antidotes  will  avail  nothing.     On  the  whole,  there- 


TREATMENT    OF    SENSITIVE    DENTINE.  287 

fore,  it  is  better  to  refrain  from  its  use  altogether  in 
the  treatment  of  sensitive  dentine. 

Alkaline  caustics  have  been  to  some  extent  used  for 
the  treatment  of  this  affection,  A  preparation  made 
after  the  following  formula  is  said  to  relieve  some 
cases  very  promptly :  Take  Canada  balsam  and 
slacked  lime,  and  having  made  them  into  a  paste,  fill 
the  cavity  partially  full  with  it,  and  permit  it  to  re- 
main until  the  object  is  accomplished. 

The  sensitiveness  of  dentine  may  be  obtunded  by 
friction  on  the  aifected  part  with  a  smooth  burnisher. 
This  method,  however,  is  applicable  only  to  those 
cases  in  which  there  is  room  to  use  the  instrument. 
On  the  surfaces  of  the  teeth,  where  there  may  be 
sensitiveness,  it  is  very  applicable  and  very  efficient. 
Simple  pressure,  without  friction,  it  is  suggested, 
will  accomplish  the  same  object,  though  pressure  and 
friction  combined  are  doubtless  more  efficient. 

During  the  last  three  or  four  years,  various  appli- 
cations have  been  introduced,  and  used  to  greater  or 
less  extent,  for  the  relief  of  sensitive  dentine  during 
the  operation  of  filling.  Moistening  a  cavity  with 
creosote,  carbolic  acid,  carvacrol,  or  oil  of  cloves,  at 
the  time  of  operating,  and  especially  in  excavating, 
will  in  many  instances  greatly  mitigate  the  pain,  and 
in  some  relieve  it  altogether. 

About   two    years   ago,    a   nostrum    denominated 


288  PATHOLOGICAL    CONDITIONS. 

"Dental  Pain  Obtunder"  was  introduced,  and  used 
by  many  in  the  profession,  and  in  many  instances 
with  decidedly  good  results.  With  it,  however,  as 
with  many  other  things,  there  was  a  variety  of 
opinions  and  experiences. 

The  use  of  any  of  these  things,  even  though  they 
would  in  any  case  give  temporary  relief,  do  not  meet 
the  difficulty  in  a  proper  manner,  except  in  those 
cases  in  which  the  affection  is  very  superficial ;  in 
every  other  case  the  aim  should  be  complete  restora- 
tion to  a  normal  condition,  and  this,  for  the  most  part, 
at  least,  must  be  accomplished  by  nature,  aided,  so 
far  as  practicable,  by  proper  systemic  and  local  treat- 
ment. 

Many  suppose  that  if  they  can  by  any  temporary 
obtunding  of  sensibility  introduce  a  filling,  all  will  be 
well.  This  often  proves  to  be  a  serious  mistake,  for 
when  a  filling  of  metal  is  placed  on  sensitive  dentine, 
the  thermnl  changes  very  often  prevent  a  return  to  a 
normal  condition,  and  in  some  cases  greatly  increase 
the  difficulty.  In  all  instances,  so  far  as  possible,  an 
entire  restoration  to  a  state  of  health  should  be 
effected  before  filling,  or  the  part  shielded  by  a  non- 
conductor. 


\ 


CHAPTER  IX. 

EXPOSED    PULPS. 

When  the  pulps  of  the  teeth  are  exposed,  it  is 
usually  in  consequence  of  decay,  but  sometimes  of  a 
gradual  wearing  down  of  the  organs  in  mastication, 
in  other  cases  by  chemical  abrasion.  When  the  pulp 
of  a  tooth  is  found  exposed,  the  course  of  remedy  to 
be  pursued  will  be  indicated  by  the  following  con- 
siderations : — 

1st.  The  constitution  and  the  vital  energy  of  the 
system. 

2d.  The  condition  of  the  mouth  and  teeth. 

3d.  The  condition  of  the  pulp. 

4th.  The  size  of  the  orifice  at  which  it  is  exposed. 

5th.  Whether  the  exposure  is  of  recent  or  of  re- 
mote origin. 

6th.  If  in  a  tooth  of  more  than  one  root. 

7th.  The  position  of  the  tooth  in  the  mouth,  and 
that  of  the  decayed  cavity  in  the  tooth. 

The  propriety  of  attempting  to  preserve  the  vitality 
of  the  pulp  after  exposure  has  been  questioned.  Some 
take  the  position  that  after  the  development  and  for- 


290  EXPOSED   PULPS. 

mation  of  the  tooth,  the  pulp  is  no  longer  of  any  use, 
and  may,  without  damage,  be  dispensed  with ; "  while 
others  maintain  that  when  the  pulp  is  destroyed,  the 
tooth  is  no  longer  of  any  value.  The  truth  is  perhaps 
a  medium  between  these  extremes.  The  pulp  of  the 
tooth  is  valuable  in  the  economy,  or  nature  would 
dispense  with  it.  Analogy  teaches  that  it  would  not 
be  retained  longer  than.it  could  subserve  some  bene- 
ficial purpose.  But  it  is  also  true  that  a  tooth  may 
be  retained  and  perform  its  proper  function  for  a  long 
time  after  the  destruction  of  its  pulp,  notwithstand- 
ing it  is  in  a  less  perfect  condition;  though  it  is 
always  desirable  to  preserve  the  life  of  the  tooth 
when  practicable,  for  the  crown  depends  on  the  pulp 
for  its  vitality,  and  living  dentine  presents  more  re- 
sistance to  decay  than  dead ;  besides,  a  dead  tooth 
never  exhibits  the  bright,  life-like  appearance  of  a 
living  one.  The  parts  about  a  dead  tooth,  too,  are 
far  more  liable  to  disease  than  those  about  a  living 
one.  These  are  only  a  few  of  the  considerations 
for  retaining  the  pulps  of  the  teeth. 

It  has  been  maintained  that  the  structure  of  the 
tooth-pulp  is  of  such  peculiar  character,  and  so  sus- 
ceptible of  diseased  action,  that  after  it  has  become 
affected,  though  but  slightly,  it  cannot  be  restored 
to  a  healthy  condition.  We  see  no  ground,  however, 
for  such  an  assumption,  except  it  be  in  the  imperfect 


TREATMENT  OF  EXPOSED  PULPS.         291 

treatment  which  this  organ  so  frequently  receives ; 
for  the  fact  of  its  delicate  structure  does  not  neces- 
sarily imply  an  impossibility  of  restoring  it  from 
disease.  The  pulp  of  the  tooth  is  endowed  with  such 
functions  as  ordinarily  render  living  tissues  suscept- 
ible of  treatment  for  abnormal  conditions,  such  as 
circulation,  nutrition,  absorption,  and  a  distribution 
of  nerves.  The  success  attending  the  methods  of 
treating  exposed  pulps  practiced  by  the  dental  pro- 
fession during  the  last  few  years  is  a  source  of  more 
encouragement  than  a  thousand  theories. 

Treatment  of  Exposed  Pulps. — In  cases  where  the 
conditions  are  favorable, — the  constitution  good,  the 
pulp  but  recently  exposed  at  a  small  orifice,  and  in  a 
healthy  condition, — treatment  may  be  instituted 
with  almost  absolute  certainty  of  success.  If  there 
is  no  inflammation  or  irritation,  therapeutic  treatment 
is  not  indicated ;  but  the  decay  should  be  removed 
and  the  cavity  formed  without  wounding  the  pulp,  if 
possible ;  though  a  slight  wound  is  of  no  serious 
consequence,  for  immediately  after  the  hemorrhage 
ceases,  the  operation  may  proceed  as  though  the  pulp 
were  intact.  There  have  been  suggested  various 
methods  for  protecting  the  pulp  in  cases  of  this  kind ; 
formerly,  the  capping  of  pulps  was  very  extensively 
practiced,  by  which  a  shield  was  thrown  over  the 
exposed  point,  so  as  to  prevent  the  filling  from  coming 


292  EXPOSED    PULPS. 

in  contact  with  it.  Various  materials  have  been 
suggested  and  used  for  caps ;  but  gold  and  lead  were 
formerly  used  for  this  purpose,  especially  when  the 
object  was  to  form  an  arch  over  the  point  of  expos- 
ure. These  caps  are  cut  out  of  thin  gold  plate,  or 
thick  sheet  lead,  of  the  proper  shape  and  size,  and 
stamped  with  a  convex  punch,  thus  receiving  such  a 
concavity  as  fits  them  for  covering  the  exposed  pulp 
without  touching  it.  A  little  groove,  of  depth  suffi- 
cient to  hold  the  cap,  and  prevent  it  from  being  dis- 
placed by  the  introduction  of  the  filling,  may  be  made 
in  the  dentine  all  round  the  orifice  of  exposure.  The 
cap  is  then  to  be  adjusted  to  its  position  in  the 
cavity,  having  been  previously  touched  round  its 
edge  with  adhesive  wax ;  the  filling  is  then  intro- 
duced in  the  usual  manner,  carefully,  so  as  not  to 
displace  the  cap  ;  and  if  this  is  of  lead,  great  caution 
is  to  be  observed  in  condensing  the  filling  above  it, 
since  it  will  be  easily  compressed. 

The  therapeutic  influence  of  lead  on  exposed  pulps 
is  supposed  by  some  to  be  definite  and  decided  ;  but 
though  lead  is  a  less  perfect  conductor  of  heat,  and 
in  this  respect  is  better  than  gold,  and  though,  in  the 
capacity  of  a  pulp-cap,  its  indestructibility  is  probably 
quite  sufficient,  yet,  if  no  change  takes  place  in  it,  it 
i^  not  very  apparent  how  it  exercises  any  therapeutic 
action  on  the   pulp.     Experience,  however,  proves 


TREATMENT  OF  EXPOSED  PULPS.         293 

that  the  success  is  quite  as  good  in  the  use  of  lead 
caps  as  in  those  of  gokl ;  and  the  former  are  more 
easily  applied. 

Another  method  of  shielding  an  exposed  pulp  is,  to 
form  an  arch  over  it  by  the  filling.  This  operation  is 
performed  by  beginning  the  filling  at  that  side  of  the 
cavity  most  easily  approached,  building  on  the  gold 
from  the  points  of  its  attachment  almost  to  the  point 
at  which  the  pulp  is  exposed,  and  then  attaching 
from  one  point  to  another  without  permitting  the 
gold  to  come  in  contact  with  the  pulp.  Care  should 
be  taken  that  the  gold  present  as  smooth  a  surface 
to  the  pulp  as  possible.  When  the  orifice  of  exposure 
has  been  well  covered  and  protected,  the  remaining 
portion  of  the  cavity  is  filled  as  usual.  This  method 
of  forming  a  protection  over  a  tooth-pulp  possesses  no 
advantage  over  the  ordinary  capj  and  being  much  more 
difficult,  it  is  impracticable  in  any  but  skillful  hands. 

This  practice  with  exposed  pulps,  however,  has 
within  the  last  few  years  been  almost  wholly  aban- 
doned, for  the  following  reasons  :  because  it  so  fre- 
quently failed  to  accomplish  the  object,  and  because 
a  better  method  of  treatment  has  been  discovered. 
It  was  found  that,  under  that  practice,  many  cases 
which  at  first  promised  well  did  not  preserve  the  life 
of  the  pulp,  though  the  fatal  results  were  not  always 
immediate — a  year  or  two,  and  in  some  instances  a 


294  EXPOSED    PULPS. 

much  longer  period,  intervening  between  the  ope- 
ration and  the  death  of  the  tooth.  In  favorable 
cases,  the  pulp,  even  after  exposure,  will,  if  protected 
from  the  influence  of  foreign  substances,  throw  out  a 
bony  deposit,  and  even  close  up  an  orifice  of  expos- 
ure, thus  forming  for  itself  a  natural  shield.  It  is 
suggested  that  the  capping  operation  is  not  the  best 
protection  for  facilitating  this  process.  It  is  probable 
that  in  some  cases  the  space  between  the  cap  and 
the  pulp,  though  it  were  large,  would  be  filled  with 
lymph ;  and  even  if  it  were  thus  filled,  a  bony  deposit 
might  not  be  made ;  and  if  it  were  not,  it  could  not 
fail  ultimately  to  prove  injurious  to  the  pulp.  But  if 
the  space  should  not  be  filled  with  lymph,  the  diffi- 
culty would  be  equally  as  great,  since  the  pulp  would 
protrude  through  the  vacuum  beneath  the  cap,  and 
necessarily  become  diseased,  since  it  would  be  irri- 
tated by  its  contact  with,  and  its  pressure  against, 
the  sharp  edges  of  dentine  at  the  orifice  of  the  cavity; 
and  it  may  remain  thus  diseased  for  a  long  time,  or 
die  at  once.  Thus  it  is,  no  doubt,  that  the  great 
majority  of  failures  occur  under  this  kind  of  treat- 
ment. In  order  to  obviate  this  difficulty,  it  has  been 
suggested  that  the  space  under  the  cap  be  filled  with 
some  appropriate  substance,  as  a  thick  solution  of 
gutta-percha  and  chloroform,  or  a  small  pledget  of 
cotton  saturated  with  collodion. 


TREATMENT  OF  EXPOSED  PULPS.         295 

The  frequent  failures  which  occur  in  capping  pulps 
have  incited  the  profession  to  seek  some  other  method 
•of  treatment.  A  vacuum  above  the  pulp  being  objec- 
tionable, some  suitable  material  is  employed  as  a 
shield  for  this,  being  placed  on  the  orifice  of  expos- 
ure, in  contact  with  the  pulp ;  and  the  filling  is  then 
introduced  without  pressure  upon  the  point  of  ex- 
posure. There  are  several  substances  that  have 
been  thus  employed,  the  chief  of  which  are  asbestos, 
oiled  silk,  collodion,  gutta-percha.  Hill's  stopping, 
and  OS  artificial.  The  material  for  this  purpose 
should  be  a  non-conductor  of  heat,  should  not  be 
subject  to  decomposition  when  in  contact  with  the 
pulp,  and  should  present  a  smooth  surface  and  be 
easily  adapted.  In  shielding  a  pulp  in  this  manner, 
it  is  important  that  pressure  be  not  made  upon  it ; 
and  there  is  not  much  liability  to  this,  where  the 
orifice  of  exposure  is  small,  but  where  it  is  large, 
much  care  is  required  in  the  introduction  and  con- 
solidation of  the  plug.  The  opinion  has  been  enter- 
tained by  some  that  the  pulp  of  a  tooth  will  not  tole- 
rate any  foreign  substance  in  contact  with  it ;  but 
facts  refute  such  an  opinion.  By  this  kind  of  protec- 
tion for  a  pulp,  secondary  dentine  is  more  likely  to 
be  developed. 

A  very  perfect  covering  for  an  exposed  pulp  may 
be  made  by  dropping  on  it  a  little  collodion  or  solu- 


296  EXPOSED   PULPS. 

tion  of  gutta-percha,  and  after  the  evaporation  of  the 
ether  or  chloroform  filling  over  it.  This  method  has 
the  advantage  of  completely  filling  and  occupying 
the  space,  and  exactly  conforming  to  the  part,  which 
is  an  important  requisite  in  this  operation.  When 
the  exposure  is  at  a  large  orifice,  if  the  pulp  is 
healthy,  and  the  constitution  of  the  patient  good,  the 
same  general  course  of  treatment  may  be  adopted, 
except  that  more  care  and  skill  will  be  necessary  in 
the  performance  of  an  operation.  Indeed,  it  is 
difficult  to  make  a  good  operation  in  cases  of  this 
kind,  using  for  the  covering  only  a  soft  or  flexible 
material. 

A  method  of  operating  that  is  probably  more  effi- 
cient than  any  other,  is  to  prepare  the  cavity  as 
already  directed,  place  on  the  pulp  two  or  three 
drops  of  collodion  or  solution  of  gutta-percha,  letting 
it  partially  stiffen,  and  then  over  this  fit  a  gold  or 
lead  cap  as  exactly  as  possible,  so  that  it  shall  rest 
on  the  solid  dentine,  far  enough  from  the  orifice  of 
exposure  to  preclude  it  from  injurious  influence  on 
the  pulp.  On  this,  the  filling  is  introduced  as  usual, 
care  being  had  not  to  displace  the  cap,  which  in  all 
cases  should  have  a  seat  made  for  it,  formed  at  the 
time  of  the  preparation  of  the  cavity. 

When  the  pulp  of  a  tooth  becomes,  by  exposure, 
inflamed  or  diseased,  some  more  special  treatment  is 


TREATMENT  OF  EXPOSED  PULPS.         297 

indicated,  and  usually  it  is  therapeutic.  In  every 
such  case,  the  treatment  will  contemplate  either  the 
preservation  of  the  pulp,  when  the  circumstances  will 
warrant;  or  when  they  will  not,  then  its  destruction 
and  removal.  The  former  of  course  is  always  to  be 
preferred,  where  practicable.  Some  of  our  best  ope- 
rators very  strongly  denounce  the  wholesale  destruc- 
tion of  the  pulps  of  the  teeth,  practiced  by  many; 
while  some  dentists  never  attempt  to  restore  and  pre- 
serve them  at  all,  however  slightly  diseased.  This,  as 
elsewhere  intimated, is  an  erroneous  practice;  for  there 
is  no  obvious  reason  why  the  pulp  of  a  tooth  may 
not  be  restored  from  disease  to  health  as  readily  as 
other  parts,  endowed  as  it  is  with  circulation,  nutri- 
tion, absorption  and  the  distribution  of  nerves.  The 
particular  kind  of  treatment  required  in  any  given 
case,  however,  will  be  controlled  by  various  circum- 
stances, such  as  the  nature  and  extent  of  the  disease, 
whether  it  is  of  chronic  or  acute  tpye.  When  the 
irritation  or  inflammation  is  but  slight,  and  is  kept 
up  solely  by  the  contact  of  irritating  substances,  res- 
toration of  the  pulp  may  be  effected  by  a  removal  of 
these  irritating  causes,  and  protection  of  the  pulp 
against  their  further  influence  :  in  such  case,  nature, 
unaided,  affects  the  restoration.  In  a  feeble  consti- 
tution, the  pulp,  though  but  slightly  affected,  will 
require  topical  therapeutic  treatment ;  and  meanwhile 


298  EXPOSED    PULPS. 

general  treatment  may  be  employed  to  give  increased 
tone  to  the  system.  In  the  local  treatment,  neutral- 
izing agents  should  be  applied  first,  and  afterwards 
such  as  will  counteract  and  reduce  inflammation, 
especially  if  this  is  in  an  active  state.  But  if  the 
pulp  is  in  a  morbid  condition,  with  retarded  circula- 
tion and  a  tendency  to  enlargement,  active  and  stimu- 
lating applications  will  be  indicated,  and  in  some 
cases  escharotics,  such  as  nitrate  of  silver,  chloride  of 
zinc,  and  chromic  acid,  the  latter  especially  where 
there  is  a  tendency  to  prurient  enlargement  of  the 
pulp.  The  therapeutic  principles  embraced  in  astrin- 
gents, tonics,  stimulants,  and  escharotics,  are  mainly 
to  be  relied  upon  in  the  topical  treatment  of  exposed 
pulp. 

The  length  of  time  requisite  for  this  treatment  will 
vary  with  different  cases.  In  the  case  of  a  recent 
acute  inflammation,  the  process  of  restoration  may  be 
completed  in  two  or  three  days  ;  while  in  other  cases, 
where  the  difficulty  is  of  long  standing  and  of  a  more 
complex  character,  it  will  require  from  a  week  to  two 
months.  The  systemic  condition  of  the  patient  also 
exercises  a  great  modifying  influence  upon  the  treat- 
ment. Leeching  and  counter-irritation  of  the  gums 
are  sometimes  resorted  to  in  this  treatment ;  but  it  is 
rare  that  any  definite  beneficial  result  ensues.  De- 
pletion of  the  pulp  itself  may  often  be  practiced  with 


TREATMENT  OF  EXPOSED  PULPS.         299 

decided  success  :  and  it  may  be  accomplished  either 
by  puncturing  the  pulp  with  a  fine-pointed  instru- 
ment, or  by  excising  a  small  portion  of  it  at  the  ori- 
fice of  exposure,  in  either  case  avoiding  laceration. 
By  this  means  the  distended  vessels  are  relieved ; 
and  in  many  cases,  where  the  difficulty  is  but  slight, 
immediately  after  such  relief  by  puncturing,  so  soon 
as  the  hemorrhage  has  ceased,  the  tooth  may  be 
filled.  But  if  the  depletion  is  by  excision,  time  must 
be  allowed  for  the  recovery  of  the  incised  surface — 
ordinarily  from  three  to  ten  days. 

A  method  of  treatment  of  exposed  pulps — first 
introduced  to  the  notice  of  the  profession  by  Dr. 
Allport,  and  one  which  in  his  hands  has  proved  quite 
successful — consists  in  the  excision  of  a  portion  of 
the  pulp  at  the  orifice  of  exposure,  drawing  the 
edges  of  the  incised  part  together,  and  inducing  their 
union,  and  in  this  manner  closing  the  wound,  when 
less  space  is  occupied  by  the  pulp  than  before  the 
operation.  After  securing  this  result,  the  operation 
of  filling  the  tooth  may  be  performed ;  the  same  care 
being  observed,  however,  as  already  suggested  in 
cases  of  exposed  pulp. 

The  employment  of  pepsin  has  been  quite  effective 
in  the  hands  of  some  practitioners.  The  method  of 
application  is  as  follows  :  with  the  pure  pepsin  in 
powder,  and  diluted  hydrochloric  acid,  or  liquid  pep- 


300  EXPOSED    PULPS. 

sin,  form  a  jDaste  of  creamy  consistence,  that  can  be 
readily  ajoplied  to  an  exposed  pulp. 

The  cases  in  which  this  preparation  seems  appro- 
priate and  efficient  are  those  in  which  there  is 
debris  and  offensive  matter  in  contact  with  and  irrita- 
ting the  pulp  that  cannot  be  readily  removed,  either 
with  an  instrument  or  by  washing.  There  is  often  a 
film  of  partially  devitalized  pulp  substance  upon  and 
covering  the  exposed  part,  that  operates  as  an  active 
irritant  to  the  tissue  beneath  it ;  this  and  all  similar 
substances  are  dissolved  and  removed  by  the  action  of 
the  pepsin  paste  ;  and  not  only  is  this  accomplished, 
but  the  pulp  is  stimulated  to  a  healthy  action. 

For  the  application  the  cavity  through  which  the 
exposure  is  effected  should  be  cleaned  thoroughly  and 
dried ;  then  place  a  drop  of  the  paste  on  the  point  of 
exposure,  on  this  put  two  or  three  plies  of  bibulous 
paper,  then  fill  the  cavity  with  wax,  softened  by 
heat,  so  that  its  introduction  will  not  cause  pressure 
upon  the  pulp.  This  should  remain  for  from  six 
to  twenty-four  hours,  when  it  should  be  removed; 
the  pulp  will  usually  now  present,  at  the  orifice  of 
exposure,  the  bright  pinkish  hue  of  the  healthy 
tissue ;  very  seldom  will  a  second  application  be 
required. 

This  condition  being  attained,  the  pulp  is  ready 
for  its  covering  for  permanent  protection. 


i^ 


TREATMENT  OF  EXPOSED  PULPS.         301 

For  the  proper  covering  and  filling  over  an  exposed 
pulp,  certain  indications  must  be  fulfilled  : 

First.  A  material  must  be  used  that  will  be  accep- 
table to  the  tissue,  that  will  in  no  degree  irritate  it. 

Second.  It  should  be  a  substance  that  will  not 
decompose  or  undergo  change  when  in  contact  with 
the  pulp. 

Third.  It  must  be  a  material  of  such  consistence  as 
to  be  made  easily  to  occupy  all  the  space  at  the  ori- 
fice of  exposure,  and  yet  make  no  pressure  upon  the 
pulp. 

Fourth.  It  should  be  a  non-conductor  of  heat  equal 
to  or  beyond  the  dentine. 

Fifth.  It  should  possess  sufficient  resistance  to 
admit  the  proper  introduction  of  the  best  material 
for  filling. 

Thus  it  is  apparent  that  the  aim  is,  and  should  be, 
to  place  the  exposed  pulp  back  again  in  as  nearly  its 
normal  state  of  closure  as  possible.  This  is  the 
criterion-  that  should  guide  in  the  performance  of  this 
most  delicate  operation. 

A  very  good  method  of  accomplishing  this  was 
suggested  by  Dr.  J.  S.  King  about  the  year  1871. 
Others  have  claimed  that  they  had  used  the  same 
principle  before. 

It  consists  in  placing  in  the  orifice  of  exposure  and 
on  the  pulp,  after  it  has  been  freed  from  all  irritants 


302  EXPOSED    PULPS. 

and  restored  to  a  state  of  health  as  nearly  as  possible, 
a  paste  of  oxyd  of  zinc  and  creosote  of  a  thick  creamy 
consistence ;  with  this  the  orifice  should  be  completely 
covered ;  remove  any  excess  of  creosote  with  bibulous 
paper ;  then  cover  this,  and  fill  the  cavity  of  decay 
with  OS  artificial  or  Guillois'  cement.  So  far  as  the 
pulp  is  concerned,  this  is  to  be  the  permanent  cover- 
ing ;  as  to  the  cavity  of  decay,  this  may  constitute 
the  permanent  filling,  or  sufficient  of  the  os  artificial 
may  be  cut  away  from  the  cavity  to  enable  it  to  be 
well  filled  with  gold,  or  any  other  material.  This  in 
the  hands  of  many  has  proved  a  very  successful 
method  of  enclosing  exposed  pulps. 

The  formation  of  secondary  dentine,  by  which  the 
orifice  of  exposure  is  closed  up,  has  already  been  re- 
ferred  to ;  and  it  has  been  suggested  that  treatment 
to  facilitate  this  process  may  be  instituted.  With  a 
view  to  this,  temporary  fillings  are  sometimes  intro- 
duced. If  a  shield  of  secondary  dentine  is  desirable 
before  permanent  filling,  the  best  method  of  securing 
it  is,  after  seeing  that  the  general  recuperative  power 
is  in  the  best  condition,  to  place  in  the  cavity  a  tem- 
porary filling,  of  such  material  and  in  such  manner  as 
will  be  most  acceptable  to  the  pulp,  and  then  leave 
nature  to  accomplish  the  work.  In  many  cases, 
especially  in  young  persons,  this  process  would  be 
facilitated  by  an  administration  of  bone  phosphate. 


TREATMENT  OF  EXPOSED  PULPS.         303 

The  pulps  of  the  teeth  of  the  young  are  more  diffi- 
cult to  treat  successfully  than  those  of  the  more 
advanced  in  life. 

A  method  of  treating  exposed  pulps  with  a  view  of 
securing  a  closure  of  the  orifice  of  exposure  by 
nature,  was  first  suggested  and  practiced  in  1873  by 
Dr.  J.  E.  Cravens,  and  consisted  of  the  following 
treatment : 

The  exposed  pulp  should  be  rendered  as  nearly 
absolutely  free  from  extraneous  matter  as  possible, 
but  softened  or  partially  decalcified  dentine  should 
remain  undisturbed  in  the  cavity.  The  cavity  should 
be  secured  against  moisture,  and  kept  so  during  the 
operation ;  being  thoroughly  clean  and  dry,  the  pulp 
exposure  should  be  covered  with  a  paste  prepared  as 
follows  :  Upon  a  warm  slab  of  ground  glass  put  a 
drop  of  Merck's  lactic  acid ;  add  twice  that  volume 
of  magma,  or  freshly-precipitated  phosphate  of  lime ; 
then  rub  till  a  complete  solution  is  effected.  This  is 
lacto-phosphate  of  lime.  To  this  solution  add  dry 
phosphate  of  lime  until  the  paste  is  of  proper  consist- 
ence for  application.  Place  this  paste  directly  on 
the  exposed  pulp  so  as  to  occupy  all  the  space,  and 
yet  make  no  pressure  upon  it;  the  cavity  may  be 
filled  from  one-fourth  to  one-third  full  of  this  mate- 
rial ;  then  remove  the  moisture  from  the  surface  of 
the  paste  with  spunk  or  some  absorbent,  then  cover 


304  EXPOSED    PULPS. 

it  with  two  or  three  plies  of  bibulous  paper,  cut  to  fit 
the  cavity  and  moistened  with  sweet  oil ;  press  this 
carefully  upon  the  paste,  especially  all  round  the 
border ;  then  cover  this  and  fill  the  cavity  with  os 
artificial,  or  its  equivalent.  Hill's  stopping  or  gutta- 
percha cannot  with  safety  be  used  instead  of  the  os 
artificial,  as  more  or  less  pressure  would  be  occasioned 
by  their  introduction.  Dr.  Cravens  suggests  that 
the  pulp  should  not  be  treated  previously  with  any- 
thing that  would  coagulate  albumen,  and  indeed 
should  have  no  preparatory  treatment  except  that 
already  referred  to. 

This  dressing  and  filling  should  remain  undisturbed 
for  from  two  to  six  weeks,  and  one  application  is 
usually  quite  sufficient  to  induce  bony  deposit  to  fill 
the  orifice  of  exposure  and  cover  the  pulp. 

Pain  will  seldom  be  experienced  after  the  applica- 
tion of  the  phosphate  of  lime  as  above  described,  but 
if  it  should,  the  use  of  sedative  treatment,  either  lo- 
cally or  through  the  system,  will  meet  the  difficulty. 
In  no  case  should  the  dressing  and  filling  be  removed 
or  disturbed  till  the  allotted  time  has  elapsed.  Dr. 
Cravens  entertains  the  opinion  that  the  phosphate  of 
lime,  thus  applied,  is  appropriated  in  the  formation  of 
the  new  deposits,  and  that  thus  the  living  tissue 
beneath  has  cooperation  in  this  process,  at  least  so  far 
as  supply  is  concerned. 


REMOVAL   OF    PULPS.  305 

Destruction  of  the  Pulp. — There  are  cases  in  which 
an  attempt  to  restore  the  pulp,  even  when  recently 
and  but  slightly  diseased,  would  prove  unavailing ;  so 
feeble  is  the  vitality  that  it  is  destroyed  at  almost 
the  first  touch.  Two  cases  in  apparently  the  same 
condition  pathologically,  but  in  different  constitu- 
tions, will,  under  the  same  treatment,  exhibit  very 
different  results.  A  pulp  in  a  system  with  low  vital 
power,  that  is  highly  diseased,  is  but  seldom,  if  ever, 
under  any  circumstances,  susceptible  of  restoration; 
and  in  such  case,  of  course,  devitalization  and  remo- 
val are  indicated.  This  was  formerly  supposed  to  be 
an  impracticable  operation,  for  two  reasons :  first, 
because  it  was  very  difficult  and  painful ;  and  second, 
because  of  the  consequences  likely  to  ensue.  Then, 
the  operation  was  attempted  only  on  teeth  having 
one  root,  and  those  of  cylindrical  form;  but  now,  it 
is  performed  successfully  on  all  classes  of  teeth. 
When  destruction  of  the  pulp  is  decided  upon,  such 
means  should  be  employed  as  will  effect  the  object 
promptly  and  thoroughly.  Everything  should  be 
entirely  removed  from  the  pulp-chamber  and  the 
canal  of  the  root,  for  any  remaining  portion  is  liable 
to  induce  inflammation  and  suppuration ;  and  alveolar 
abscess  also  frequently  ensues. 

There  are  two  methods  of  destroying  the  pulp : 
the  one,  by  an  operation ;  the  other,  by  the  applica- 


306  EXPOSED   PULPS. 

tion  of  some  devitalizing  agent.  The  choice  of  these 
methods  will  be  governed  by  circumstances,  such  as 
the  temperament  of  the  patient,  the  condition  of  the 
tooth  and  parts  about  it,  and  the  class  of  the  tooth  to 
be  operated  upon.  For  patients  of  a  nervous,  irri- 
table temperament,  to  whom  a  removal  of  the  pulp 
by  an  operation  would  occasion  great  pain  and  a 
severe  shock,  it  would  be  better  to  apply  some  agent 
to  destroy  the  vitality  of  the  pulp,  and  then  remove 
it ;  but,  on  the  contrary,  where  there  is  vigor,  and  a 
capacity  of  endurance,  it  is  preferable  to  remove  the 
pulp  at  once  by  an  operation.  To  accomplish  this, 
there  are  two  or  three  methods  of  manipulation.  In 
the  first  place,  however,  by  whatever  method  it  is 
removed,  it  should  be  fully  exposed ;  the  orifice  of 
exposure  should  be  as  large  as  the  pulp-chamber, 
and  the  entrance  as  nearly  as  possible  on  a  line  with 
the  tooth's  axis ;  hence  it  will  be  necessary  in  many 
cases  to  make  an  opening  into  the  pulp-chamber  at  a 
point  different  from  that  of  the  opening  caused  by  the 
decay.  For  instance,  in  the  incisor  teeth,  when  the 
decayed  cavity  is  small,  on  the  side,  near  the  margin 
of  the  gum,  penetrating  to  the  pulp-chamber,  and 
exposing  the  pulp,  the  entrance  through  this  opening 
into  the  canal  will  be  almost  at  right  angles  with  it ; 
and  in  such  case  it  would  be  impossible,  through  this 
opening,   to   manipulate   freely  in  the  root,   and  it 


REMOVAL    OF    PULPS.  307 

would  be  necessary  to  make  an  opening  with  a  drill 
through  the  palatal  portion  of  the  tooth  directly  into 
the  canal  and  on  a  line  with  it,  which  opening  should 
be  large  enough  readily  to  allow  of  a  removal  of  the 
pulp  through  it,  and  of  an  unimpeded  performance  of 
all  the  subsequent  operations  in  the  canal  of  the  root. 
After  the  pulp  has  been  exposed  by  the  proper 
opening,  the  instrument  should  be  selected  for  its  re- 
moval. There  are  different  forms  of  instruments  for 
this  purpose.  Some  operators  employ  the  untem- 
pered,  four-sided,  barbed  broach,  thrusting  it  into  the 
canal  as  far  as  possible,  then  turning  it  two  or  three 
times  around,  and  thus  wrapjxng  the  pulp  round  the 
instrument,  when  both  are  drawn  away  together. 
This  method  always  occasions  considerable  pain. 
Others  employ  simply  the  three  or  four-sided  broach, 
thrusting  it  through  the  pulp  all  the  way  up  the 
canal,  and  thus  lacerating  it  and  breaking  up  its 
structure,  so  that  it  may  afterward  be  removed  with- 
out much  pain.  Another  method,  and  one  which 
seems  preferable  to  all  the  others,  is  as  follows : 
Take  a  very  fine  untempered  steel  wire,  round  and 
smooth,  not  larger  than  34  to  36  of  Stub's  gauge- 
plate  ;  flatten  the  extreme  point,  and  turn  it  to 
an  angle  of  from  thirty  to  forty  degrees;  place 
the  end  of  this  against  one  wall  of  the  canal 
at   the   point    of  exposure   of   the   pulp;    press    it 


308  EXPOSED    PULPS. 

steadily  up  the  canal,  with  its  edge  bearing  against 
the  wall,  as  far  as  it  will  go,  and  then  twirl  it  sud- 
denly round.  Thus  an  incision  is  effected  near  the 
point  of  the  root,  when  the  pulp  with  the  instrument 
may  be  drawn  away  together;  or,  if  not  thus  re- 
moved, it  may  be  caught  with  some  fine  point,  and 
removed  with  little  or  no  pain.  This  manner  of 
introducing  the  instrument,  too,  causes  less  pain  than 
either  of  the  others,  for  there  are  no  sharp  edges  or 
points  presented  in  passing  the  instrument  up  the 
canal,  to  cut  or  lacerate  the  pulp.  In  the  removal 
of  the  pulp  from  the  teeth  of  young  persons,  care 
should  be  taken  lest  the  instrument  pass  entirely 
through  the  foramen,  at  the  apex  of  the  root ;  but 
with  adults  there  is  little  or  no  danger  of  such  an 
accident. 

The  directions  here  given  would  be  quite  sufficient, 
if  closely  followed,  for  the  removal  of  the  pulps  of  the 
six  anterior  superior  teeth.  For  the  removal  of  the 
pulps  from  the  bicuspids,  the  entrance  can  ordinarily 
be  effected  through  the  decayed  cavity.  Usually 
there  is  some  lateral  compression  of  the  roots  of  these  ^| 
teeth ;  and  the  canal  through  the  root  corresponds  in 
its  formation,  so  that  it  represents  a  mere  fissure, 
expanded  a  little  on  each  side  of  the  centre.  It  is  often 
difficult,  and  requires  very  delicate  manipulation,  to 
remove  all  the  pulp  from  these  fissures.    A  very  fine 


REMOVAL    OF   PULPS.  309 

instrument  may  be  pressed  down  each  side,  and  yet 
a  portion  of  the  pulp  remain  in  the  centre.  This  dif- 
ficulty is  most  fully  presented  in  those  cases  in  which 
there  has  been  an  apparent,  though  abortive,  effort 
of  nature  to  produce  two  roots. 

The  removal  of  the  pulps  of  the  molar  teeth  is  a 
more  extensive  and  complicated  operation.  The  pulp 
to  be  operated  upon  should  be  fully  exposed,  the 
orifice  of  exposure  being  made  as  nearly  as  possible 
of  the  size  of  the  pulp-chamber ;  and  the  instrument 
to  be  used  should  be  such  as  last  described,  except 
that  it  should  be  much  larger,  and  is  to  be  intro- 
duced, in  the  same  manner,  to  the  bottom  of  the 
pulp-chamber,  and  rotated  suddenly,  so  as  to  cut  off 
the  ramifications  of  the  pulp  into  the  roots,  thus  at 
one  sweep  dislodging  the  entire  body  of  it  without 
laceration.  The  practice  of  plunging  a  large  barbed 
or  cutting  instrument  into  the  pulp  of  a  molar  tooth 
is  painful  in  the  extreme. 

The  pain  of  removing  the  living  tooth-pulp  may  be 
much  mitigated  in  all  cases,  and  in  many  prevented 
altogether,  by  the  use  of  local  anaesthesia.  This  may 
be  effected  by  the  application  of  chloroform,  or  some 
one  of  the  various  anaesthetics  that  are  available, 
directly  to  the  pulp.  The  application  of  cold  is  quite 
efficient ;  this  may  be  effected  by  the  use  of  ether 
spray  or  ice.    So  extended  have  become  the  facilities 


310  EXPOSED    PULPS. 

for  inducing  local  anaesthesia,  that  the  spray  or  ice 
need  hardly  be  employed. 

The  branches  of  the  pulp  in  the  roots  should  be 
removed  in  the  manner  already  directed  for  the  re- 
moval of  the  pulps  from  teeth  of  single  roots.  The 
palatal  root  is  very  easily  operated  upon ;  but  as  to 
the  buccal  roots,  there  is  frequently  encountered  the 
same  difficulty  referred  to  in  speaking  of  the  bicus- 
pids. When  a  pulp  is  removed  in  this  manner,  the 
wound  commonly  heals  by  first  intention,  and  there 
is  formed  a  permanent  cicatrix. 

Actual  Cautery. — rFor  destroying  tooth-pulp,  the 
actual  cautery  was  formerly  employed  to  a  conside- 
rable extent,  and  was  at  one  time  a  favorite  method 
W'ith  French  dentists.  This  consists  in  heating  a 
wire  of  proper  size  to  a  white  heat,  and  thrusting  it 
into  the  canal  of  the  root  to  the  apex,  the  object 
being  to  destroy  the  pulp  the  instant  the  wire  comes 
in  contact  with  it.  The  operation  requires  much 
skill,  and  is  attended  with  many  difficulties.  It  is 
fraught  with  terror  to  the  patient ;  if  the  temperature 
of  the  wire  is  not  at  white  heat  at  the  time  of  its 
insertion,  the  pain  of  the  operation  is  most  intense ; 
it  is  liable  to  leave  the  parts  in  such  a  condition  as 
often  to  induce  inflammation  and  suppuration,  which 
may  involve  the  investing  membrane  and  the  sur- 
rounding parts.     Besides,  by  this  method,  the  object 


I 


REMOVAL    OF   PULPS.  311 

is,  at  best,  no  more  successfully  attained  than  by 
others. 

The  galvanic  cautery  has  been  employed  to  some 
extent  in  general  surgery,  and  it  is  very  probably 
the  best  form  in  which  the  actual  cautery  can  be 
applied  for  destroying  pulps  of  teeth. 

Potential  Cautery. — This  term  is  applied  to  those 
therapeutic  agents  which  destroy  vital  tissue  by 
establishing  a  condition  incompatible  with  vitality. 
Many  preparations  have  been  employed  as  topical 
applications  to  devitalize  the  pulps  of  teeth,  but  only 
two  or  three  to  any  considerable  extent.  A  conside- 
ration of  the  nature  and  something  of  the  specific 
action  of  these  agents  may  not  here  be  out  of  place. 
And  first,  of 

Arsenioiis  Acid. — This  has  been  more  used,  topi- 
cally, for  the  destruction  of  tooth-pulp  than  all  other 
applications.  The  first  account  we  have  of  its  use  for 
this  purpose  dates  back  to  1836,  Avhen  it  was  applied 
by  Dr.  Spooner,  though  others  claim  to  have  em- 
ployed it  about  the  same  time.  The  specific  action 
of  arsenious  acid  on  vital  tissue  is  not  well  under- 
stood. It  is  supposed  by  some  that  it  forms  a  com- 
pound with  some  element  of  the  tissue,  and  in  this 
way  destroys  the  vitality. 

Any  such  combination,  however,  has  hitherto 
escaped  detection;  and  it  is  certain  that  if  a  com- 


312  EXPOSED   PULPS. 

pound  is  formed,  it  is  not  fixed  or  permanent  in  its 
character,  since  the  arsenic  will  be  carried  to  different 
parts  of  the  system,  and  its  specific  influence  mani- 
fested wherever  it  goes,  which  could  not  be  the  case 
if  it  formed  a  fixed  compound.  The  more  probable 
theory  is  that  it  destroys  vitality  by  its  influence  on 
nerve  tissue,  producing  such  a  change  in  its  structure 
as  to  arrest  its  function  at  once.  In  reference  to  the 
action  of  this  agent  upon  living  tissue,  much  investi- 
gation remains  to  be  made.  Animal  tissue  takes  it 
up  by  imbibition ;  and  it  is  also  absorbed  by  the  cir- 
culation, and  conveyed  by  it,  as  already  suggested, 
throughout  the  system.  Frequently,  however,  it  is 
applied  to  living  tissue,  under  conditions  that  prevent 
such  absorption.  It  is  often  employed  in  the  treat- 
ment of  carcinoma.  In  the  application  of  arsenious 
acid  to  the  pulps  of  teeth,  for  their  destruction,  seve- 
ral circumstances  are  to  be  considered,  such  as  the 
age  of  the  patient,  the  constitutional  tendency,  the 
vascularity  of  the  dentine.  Where  the  vascularity  is 
great,  the  utmost  caution  is  required.  The  indis- 
criminate use  of  this  agent  in  the  teeth  of  the  young 
is  attended  with  great  risk.  Some  constitutions  are 
peculiarly  susceptible  to  its  influence,  experiencing 
its  effects  even  in  remote  parts  of  the  system,  after 
its  application  only  to  the  pulp  of  a  tooth.  It  is 
soluble  in  creosote  and  most  of  the  essential  oils. 


« 


REMOVAL    OF    PULPS.  313 

and  to  some  extent  in  alcohol  and  water.  In  many 
cases  when  it  is  applied  to  the  pulp  of  a  tooth,  more 
or  less  disturbance  of  the  periosteum  is  exhibited  a 
short  time  after — in  some  instances  in  a  few  hours, 
and  in  others  after  several  days,  thus  giving  evi- 
dence that  it  has  by  some  means  come  in  contact 
with  the  periosteum.  Its  influence  on  this  will  often 
be  manifested  under  percussion,  in  advance  of  any 
other  symptom. 

Application. — There  are  two  or  three  methods  of 
applying  arsenious  acid  for  the  destruction  of  the 
pulps  of  teeth.  The  ordinary  arsenic  of  commerce  is 
used.  It  was  formerly  employed  very  extensively  in 
connection  with  sulphate  of  morphia,  mixed  in  equal 
parts,  and  applied  to  the  pulp  with  a  small  pledget 
of  cotton,  moistened  with  creosote  or  some  essential 
oil,  the  former  being  most  frequently  used.  Alcohol, 
ether,  or  water  may  be  employed  instead  of  creosote. 
and  in  some  respects  and  in  some  cases  would  be 
preferable.  The  pledget  of  cotton,  thus  prepared,  is 
introduced  into  the  decayed  cavity,  with  the  prepa- 
ration in  contact  with  the  exposed  pulp.  Another 
pledget  of  cotton,  saturated  with  a  thick  solution  of 
gum  sandarac  and  alcohol,  or  gutta-percha  and  chloro- 
form, is  placed  over  this  in  the  cavity,  to  prevent  the 
escape  of  the  preparation,  or  the  entrance  of  moisture 
or  foreign  substances.    Any  preparation  may  be  used 


314  EXPOSED    PULPS. 

that  will  accomplish  these  objects.  In  the  applica- 
tion of  the  pledget,  care  must  be  exercised  lest  too 
much  pressure  be  made  on  the  pulp,  and  pain  be  thus 
produced.  In  order  to  prevent  this  pressure,  another 
method  has  been  adopted,  which  consists  in  forming 
a  cap  of  lead,  placing  it  in  the  arsenic,  in  the  dry 
state  or  with  some  suitable  solvent,  and  then  fitting 
it  over  the  exposed  pulp,  and  retaining  it  there  with 
a  pledget  of  cotton,  as  above,  or  with  Hill's  stopping, 
gutta-percha,  or  adhesive  wax.  Thus  the  preparation 
comes  gently  in  contact  with  the  pulp,  and  prevents 
any  pressure  on  it.  The  morphine  is  used  for  the 
purpose  of  diminishing  the  pain  which  frequently 
results  from  the  application  of  arsenic  only ;  but  its 
influence  for  such  a  purpose  is  predicated  more  on 
theory  than  on  practice ;  for  facts  prove  that,  applied 
to  living  tissue,  it  produces  pain  rather  than  allays 
it.  Therefore  the  more  observing  and  better  class  of 
practitioners  have  discarded  it. 

Other  substances  have  been  mixed  with  arsenic, 
for  the  purpose  of  mitigating  or  altogether  relieving 
the  deleterious  consequences  so  liable  to  follow  its 
administration;  as,  for  instance,  pulverized  charcoal, 
which,  combined  with  it  in  equal  parts  by  weight, 
makes  a  favorite  preparation  with  some  practitioners, 
by  whom  it  is  claimed  that  the  charcoal  counteracts 
the  specific  effect  of  the  arsenic  on  parts  other  than 


REMOVAL    OF   PULPS.  315 

those  for  which  it  is  directly  designed.  But  this 
theory,  in  the  light  of  any  elucidation  yet  given,  is 
very  vague.  The  claim  cannot  be  that  charcoal  is  an 
antidote  to  arsenic,  since  facts  refute  it;  for  if  it 
were,  the  arsenic  of  the  pref)aration,  when  applied  to 
the  pulp  of  a  tooth,  would  fail  of  its  effect,  because 
the  charcoal  being  also  in  contact  with  the  pulp, 
would  there,  if  ever,  counteract  the  poison.  But  this 
it  does  not  do,  for  the  pulp  is  destroyed  about  as 
readily  by  this  preparation  as  by  arsenic  alone.  And 
if  when  the  arsenic  and  charcoal  are  thus  together  no 
counteracting  influence  of  the  latter  is  manifest, 
much  less  will  there  be  any  when  the  arsenic, 
escaped  from  the  charcoal,  runs  riot  through  the  tis- 
sues, whither  the  latter  cannot  follow.  The  only 
probable  advantage,  then,  of  this  preparation  is,  that 
the  arsenic  is  not  taken  up  from  it  by  the  tissues 
so  rapidly  as  when  it  is  applied  alone,  or  with  any- 
thing that  is  soluble  with  it ;  for  when  thus  applied, 
the  whole  is  very  soon  dissolved,  and  taken  up  by 
the  pulp  and  dentine.  But  when  combined  with 
charcoal  or  the  like,  little  more  of  the  arsenic  is 
absorbed  than  that  which  comes  in  contact  with  the 
pulp.  Hence  the  conclusion  that  the  influence  of  the 
charcoal  is  mechanical,  and  not  therapeutic. 

This  preparation  is  better  applied  perfectly  dry, 
beneath  a  lead  cap,  which  should  completely  close 


316  EXPOSED   PULPS. 

the  cavity.  Any  other  material  that  would  mix  as 
readily  with  the  arsenic,  without  being  soluble,  and 
that  would  not  induce  irritation  when  in  contact  with 
the  pulp,  would  be  quite  as  good  for  this  purpose  as 
charcoal.  Irritating  gases  generated  in  a  tightly- 
closed  cavity  are  absorbed  by  charcoal. 

Cobalt,  in  which  the  active  principle  is  arsenic, 
has  been  extensively  used  for  destroying  pulps ;  but 
it  is  in  no  respect  superior,  and  in  some  respects  it  is 
probably  inferior,  to  the  preparation  of  charcoal  and 
arsenic ;  it  is  applied  in  the  same  manner. 

The  length  of  time  the  preparation  should  remain 
in  the  tooth  will  be  determined  by  the  condition  of 
the  pulp  when  it  is  applied,  the  age  of  the  patient, 
the  vascularity  of  the  dentine,  the  susceptibility  of 
the  patient  to  the  influence  of  arsenic,  and  like  cir- 
cumstances. It  will  usually  be  from  three  to  twenty- 
four  hours.  In  some  cases  a  very  small  particle  will 
thoroughly  accomplish  the  work,  while  in  others  a 
much  larger  quantity  may  remain  in  contact  with  the 
pulp  even  for  a  much  longer  time,  without  producing 
more  than  a  superficial  result.  And  cases  occasion- 
ally occur  in  which  it  seems  almost  impossible  to 
destroy  the  vitality  of  a  pulp  with  arsenic.  A  case  is 
on  record  in  which  the  pulp  was  first  faii'ly  exposed 
in  a  superior  bicuspid  tooth,  the  health  and  constitu- 
tion being  good,  and  the  temperament  sanguino-lym- 


REMOVAL   OF   PULPS.  317 

phatic ;  and  arsenic  with  morphine  was  applied  to  it, 
directly,  five  times  within  ten  days,  without  pro- 
ducing any  apparent  effect ;  then  an  application  of 
creosote  and  tannin  was  made  three  or  four  times, 
during  as  many  days ;  afterward  the  tooth  was  tem- 
porarily filled  with  gutta-percha;  and  finally,  in  ten 
or  twelve  days,  this  filling  being  removed,  the  pulp 
appeared  in  a  perfect  state  of  preservation  and  health, 
with  all  the  indications  of  undiminished  vitality. 
Over  the  exposed  point  there  was  placed  a  non-con- 
ductor, and  upon  it  a  filling  of  gold,  and  one  year 
after,  the  tooth  presented  the  appearance  of  perfect 
life  and  health,  having  given  the  patient  no  annoy- 
ance during  the  whole  period. 

Hence,  it  is  quite  obvious  that  there  is  a  great 
diversity  of  susceptibility  to  the  influence  of  arsenic, 
and  that  the  study  of  these  idiosyncrasies  is  both 
interesting  and  valuable.  The  occurrence  of  injurious 
consequences  from  the  use  of  arsenic  has  induced 
many  operators  to  abandon  it  altogether.  But  these 
injurious  results  perhaps  occur  always  either  through 
mal-administration  or  from  a  peculiar  susceptibility 
to  the  influence  of  the  drug,  and  a  superior  skill  and 
a  more  accurate  diagnosis  would  avoid  them  almost 
entirely.  After  the  desired  result  with  arsenic  has 
been  obtained,  it  has  been  thought  that  antidotes  to 
arrest  its  further  operation  might  be  made  available. 


318  PULP-CAVITIES. 

The  hyilrated  sesquioxyd  of  iron  is  one  of  the  best 
antidotes  to  arsenic,  and  has  been  used  in  the  teeth 
to  counteract  its  injurious  effects  ;  but  it  is  of  no 
avail  here ;  the  arsenic  has  the  start  of  it,  and, 
indeed,  would  outstrip  it,  with  an  equal  start. 

From  the  foregoing  in  regard  to  arsenic  as  an 
application  for  destroying  the  pulps  of  teeth,  the 
following  conclusions  are  justly  deducible :  it  is,  in 
general,  very  efficient ;  it  is  a  heroic  agent ;  it  should 
in  all  cases  be  used  with  great  caution;  in  some 
Cases  it  is  entirely  inadmissible  ;  a  free  administration 
of  it  is  liable  to  be  followed  by  bad  consequences; 
and  skill  and  care,  rather  than  counteracting  agents, 
are  to  be  relied  upon  in  its  application. 

Filling  Pulp-Cavities  and  Canals. — After  the  pulp 
of  a  tooth  has  been  .destroyed,  whether  by  an  opera- 
tion or  by  therapeutic  treatment,  the  part  at  the 
point  of  its  detachment  should  in  most  cases,  before 
the  filling  is  introduced,  be  rendered  healthy ;  if  pos- 
sible, a  permanent  cicatrice  should  be  formed.  In 
cases,  however,  of  good  constitution  and  strong  recu- 
perative power,  where  a  pulp  has  been  removed  by 
an  operation,  the  root  may  be  filled  as  soon  as  the 
hemorrhage  has  ceased ;  but  such  cases  rarely  occur. 
Generally  the  part  will  require  treatment;  and  the 
character  and  duration  of  this  will  be  determined  by 
circumstances — as,  the  vital  energy  of  the  system, 


I 


TREATING    PULP-CAVITIES.  319 

and  the  method  employed  for  the  pulp's  destruction. 
When  this  has  been  effected  by  an  operation,  the 
wound  produced  by  an  excision  is  restored  to  sound- 
ness much  more  readily  than  when  by  an  application 
of  arsenious  acid,  and  less  topical  treatment  will  ordi- 
narily be  required ;  indeed,  in  many  such  cases  there 
will  be  nothing  else  required  than  to  keep  the  canal 
well  cleansed,  so  as  to  obviate  any  irritation  that 
otherwise  might  be  induced  by  decomposition.  When 
the  pulp  has  been  destroyed  by  arsenious  acid,  more 
energetic  treatment  is  usually  demanded ;  for  then 
there  is  always  a  greater  or  less  disposition  to  slough 
or  discharge  through  the  tooth,  which  must  of  course 
be  entirely  abated  before  the  operation  of  filling  is  at 
all  admissible.  In  the  treatment  of  this  condition, 
the  canal  should  be  kept  perfectly  clean  by  frequent 
syringing;  floss  silk,  moistened  with  creosote  and 
tannin,  should  be  introduced  to  the  extreme  part  of  the 
cavity  or  canal,  and  should  be  changed  every  twenty- 
four  hours,  the  cavity  being  thoroughly  washed  each 
time.  It  will  be  necessary  in  many  cases  to  continue 
this  treatment  for  several  days.  In  order  to  deter- 
mine whether  the  condition  is  such  as  to  admit  of 
the  filling,  the  floss  silk  should  be  removed  after  a 
sufficient  time  is  supposed  to  have  elapsed,  the  cavity 
thoroughly  cleansed  and  dried,  and  a  portion  of  dry 
floss  silk  or  cotton  introduced  loosely  into  the  canal. 


320  PULP-CAVITIES. 

Then  close  up  the  decayed  cavity  with  adhesive  wax, 
gutta-percha,  or  some  other  substance  that  will  effect- 
ually exclude  the  moisture ;  let  it  remain  thus  from 
twelve  to  twenty-four  hours  ;  then  open  the  cavity 
and  withdraw  the  silk  or  cotton,  and  if  this  is  found 
free  from  moisture  or  odor,  the  tooth  is  ready  to  be 
filled. 

The  treatment  just  described  will  be  sufficient  for 
all  cases  in  which  the  pulp  has  been  destroyed  by  the 
operator.  But  teeth  whose  pulps  are  already  dead 
would  seem  to  be  less  difficult  of  treatment  and 
filling ;  yet  such  is  not  the  case ;  indeed,  the  thera- 
peutic treatment  of  these  is  usually  more  protracted, 
and  their  diseased  condition  less  easily  controlled ; 
and  this  because  of  the  fact  that  the  decaying  pulp 
remaining  in  the  canal  becomes  very  offensive  and 
irritating  to  the  living  parts  adjacent,  in  which  it 
induces  a  chronic  diseased  condition,  frequently  in- 
volving the  dentine  along  the  walls  of  the  canal  in 
decomposition. 

A  classification  of  these  teeth,  based  on  their  con- 
ditions, might  be  somewhat  auxiliary  to  a  further 
examination  of  this  subject ;  and  the  following  will 
probably  embrace  them  all : — 

1st.  Those  whose  pulps  are  dead,  but  their  attach- 
ment and  adjacent  parts  alive  and  healthy. 

2d.  Those  predisposed  to  disease. 


TREATING    PULP-CAVITIES.  321 

3d.  Those  already  diseased,  either  discharging  acrid 
matter  through  the  root,  or  exhibiting  inflammation 
of  the  periosteum. 

4  th.  Those  having  alveolar  abscess. 

Sound  or  slightly  decayed  teeth  are  sometimes 
found  with  dead  pulps.  This  condition  may  be  pro- 
duced in  various  ways  :  by  blows,  or  by  any  force 
that  will  partially  loosen  the  tooth ;  by  undue  press- 
ure in  filling ;  by  excessive  sensitiveness  of  the  den- 
tine, even  where  the  decay  is  not  extensive ;  and, 
sometimes,  by  a  filling  of  the  tooth  when  it  is  in  an 
unfit  state  for  the  operation.  Ordinarily,  in  cases  in 
which  the  pulp  is  dead  before  its  exposure,  and  there 
is  no  abscess  from  the  root  or  periosteum,  the  pulp- 
chamber  may  be  opened  and  the  remains  of  the  pulp 
removed.  The  canal  should  then  be  cleansed  out, 
and  floss  silk,  moistened  with  creosote,  introduced  and 
permitted  to  remain  from  one  to  six  hours,  when  it 
should  be  withdrawn,  the  pulp  cavity  and  the  canal 
again  thoroughly  cleansed,  when,  if  there  is  no  dis- 
charge of  pus  through  the  root,  it  may  be  filled. 
The  fact  that  the  dead  pulp  is  inclosed  in  its  chamber 
without  producing  irritation  is  evidence  that  there  is 
no  secretion  of  pus.  Occasionally,  where  the  pulp 
has  died  from  exposure,  the  living  part  immediately 
adjacent  will  present  a  healthy  condition,  and  there 
will  be  no  discharge ;  such  cases  should  be  treated  in 


322  PULP-CAVITIES. 

the  manner  just  described.  In  operating  on  teeth 
ah'eady  dead,  more  delicate  manipulation  is  requisite 
to  prevent  irritation  than  on  those  in  which  the  pulp 
is  destroyed  by  the  operator.  In  very  many  cases 
of  dead  teeth,  where  there  is  not  a  state  of  actual 
disease,  there  is  a  strong  predisposition  to  it ;  and  in 
these  cases  the  preparation  of  a  cavity,  or  the  intro- 
ducing and  condensing  of  a  filling,  may  produce  in- 
flammation of  the  periosteum.  When  such  a  conditon 
is  recognized,  several  sittings  may  be  required  to 
complete  the  operation.  It  is  not  always  easy  to 
recognize  such  a  predisposition ;  yet  whenever  it  is 
suspected,  it  is  well  to  press  the  investigation,  which 
may  be  guided  by  the  following  rules.  Ascertain 
whether  the  tooth  experiences  a  different  sensation  or 
any  pain  under  percussion  in  any  direction ;  whether 
periostisis  has  ever  existed  in  that  or  in  a  contiguous 
tooth  ;  whether  the  parts  adjacent  to  the  tooth  are  in 
a  healthy  state  ;  whether  there  is  a  general  inflamma- 
tory diathesis  or  an  enfeebled  condition.  These  are 
the  prominent  points  in  an  examination  of  this  kind. 
Where  this  predisposition  exists,  it  may  be  coun- 
teracted by  general  or  local  treatment,  according  as 
it  depends  on  general  or  local  causes ;  but  in  every 
case,  this  treatment  should  be  very  carefully  con- 
ducted, and  it  will  in  some  instances  have  to  be 
protracted.    In  those  cases  where  there  is  a  discharge 


TREATING    PULP-CAVITIES.  323 

through  the  root  of  the  tooth,  such  treatment  should 
be  adopted  as  will  most  speedily  and  effectually  sup- 
press it ;  and  if  it  proceeds  from  a  remaining  portion 
of  the  pulp-tissue  near  the  point  of  the  root,  this 
should  be  removed,  and  such  application  made  as 
will  prevent  a  recurrence  of  the  discharge,  and  assist 
the  part  to  recover  its  health.  The  discharging  sur- 
face may  be  broken  up  by  cutting  it  away  with  an 
instrument,  or  be  destroyed  with  an  escharotic — 
either  nitrate  of  silver,  creosote,  or  chloride  of  zinc, 
in  the  use  of  which,  several  applications  will  in 
many  cases  be  necessary.  From  their  action,  the 
secreting  surface  is  destroyed,  healthy  granulations 
spring  up,  and  a  healthy  condition  is  established. 

The  discharge  should  be  wholly  suppressed  before 
the  tooth  is  filled,  otherwise,  alveolar  abscess  would 
probably  occur.  In  cases  where  there  is  periostitis, 
it  must  be  subdued  before  the  tooth  will  tolerate  the 
operation  of  filling.  To  attain  this  end,  the  treat- 
ment required  will  be  dictated  by  the  nature  of 
the  causes  which  operate  to  induce  the  disease. 

The  periostitis  of  teeth  whose  pulps  are  dead  com- 
monly has  its  origin  at  the  point  of  the  root,  from 
irritation  induced  in  the  beginning  by  the  dead  and 
decomposing  pulp  and  other  matter  at  that  point.  In 
many  instances  the  inflammation  is  not  confined  to 
the  root  of  the  tooth  on  which  it  began,  but  it  will 


324  PULP-CAVITIES. 

extend  to  the  alveolus,  the  gums,  and  the  periosteum 
of  the  neighboring  teeth.  Whenever  the  existence 
of  this  disease  is  suspected,  and  .yet  not  very  appa- 
rent, as  is  often  the  case,  the  examination  should  be 
very  thorough.  In  some  instances,  percussion  of  the 
tooth  at  one  particular  point,  and  at  a  certain  angle, 
will  produce  pain;  whereas,  striking  on  any  other 
part  of  the  tooth,  or  at  any  other  angle,  will  cause 
none  at  all.  By  an  exercise  of  care  and  discrimina- 
tion, the  exact  point  of  disease,  even  if  confined  to 
a  small  space,  may  be  ascertained.  For  instance,  if 
striking  on  the  labial  surface  of  a  central  incisor, 
near  the  point,  produces  pain  in  the  socket,  while  on 
any  other  point  it  does  not,  the  place  of  the  inflam- 
mation is  the  anterior  portion  of  the  root,  at  or  near 
its  point.  By 'such  means  Ihe  skillful  and  discern- 
ing will  be  enabled  to  form  a  tolerably  accurate 
opinion  as  to  the  extent  and  location  of  periostitis  in 
all  cases ;  and  this  is  an  important  consideration,  for 
if  inflammation  is  found  confined  to  a  small  portion 
of  a  root,  the  treatment,  if  local,  should  be  as  near 
that  point  as  possible. 

Inflammation  of  the  periosteum  may  sometimes  be 
induced  by  the  presence  of  foreign  substances  forced 
down  between  the  free  margin  of  the  gum  and  the 
neck  of  the  tooth,  which  have  remained  there  till 
they  have  become  vitiated,  so  as  injuriously  to  affect 


I 


FILLING    PULP-CANALS.  325 

the  gums  and  periosteum.  A  deposit  of  salivary  cal- 
culus sometimes  produces  inflammation  of  the  gums 
and  periosteum.  Teeth  otherwise  healthy  are  in 
some  instances  thus  affected,  though  those  which 
have  lost  their  internal  vitality  are  much  more  liable 
to  such  disease. 

Preparing  the  Teeth  and  Roots  for  Filling. — After 
the  tooth  has  been  brought  to  a  healthy  condition, 
the  decayed  cavity  is  first  to  be  excavated  and  made 
of  proper  form,  the  pulp-chamber  to  be  shaped,  and 
then  the  canals  and  the  roots  to  be  prepared  for  fill- 
ing. For  the  preparation  of  decayed  cavities  here, 
the  directions  hitherto  given  on  that  subject  will  be 
quite  sufficient.  In  the  formation  of  the  pulp-cham- 
ber, the  abrupt  projecting  portions  of  dentine  should 
be  cut  down ;  and  if  there  is  any  decomposition  of 
this,  it  should  be  removed.  The  pulp-chamber  may 
be,  when  it  is  excavated,  of  a  general  retaining  form, 
or  there  may  be  retaining-points  made  within  it  at 
proper  situations.  In  the  preparation  of  the  canal 
in  the  roots,  some  operators  do  nothing  more  than 
cleanse  them  thoroughly.  Another  method  is  to  pass 
fine  bur-drills  into  them  as  far  as  practicable,  thus 
making  the  opening  of  the  same  size  all  the  way,  or 
to  scrape  out  the  canal  with  a  fine  No.  10  excavator. 
Very  fine,  delicate  instruments  are  required  for 
cleansing   out   and   forming   the    canals ;    and  they 


326 


PULP-CAVITIES. 


should  be  quite  elastic  and  of  low  temper.  A  set  of 
instruments  for  forming  the  canals  in  the  roots  of  the 
teeth  have  been  devised  and  made  by  Dr.  C.  Palmer. 
These  are  of  such  forms  and  sizes  as  to  be  suitable 
for  every  case.     They  are  represented  in  Fig.   90. 


Fig.  90. 


Before  the  introduction  of  these  instruments,  the 
method  of  forming  these  canals  was  by  the  use  of  a 
three  or  four-sided  broach,  tapering  to  a  sharp  point, 
and  in  inclination  corresponding  as  far  as  possible  to 
that  of  the  canal.  This  instrument  is  employed  to 
enlarge  the  canal,  and  give  it  a  regular  shape;  a 
variety  should  be  at  hand,  so  that  one  of  the  proper 
size  and  taper  can  be  selected.  In  cleansing  and 
forming  the  canal,  care  is  necessary  to  prevent  the 
instrument  from  passing  entirely  through  the  point 


FILLING    PULP-CANALS.  327 

of  the  root.  Such  an  accident  is  not  very  liable  to 
occur  with  the  tapered  broach ;  but  with  the  minia- 
ture excavator,  or  barbed  wire,  it  is,  especially  in  the 
teeth  of  the  young,  where  the  foramina  through  the 
roots  are  large  ;  and  it  is  especially  liable  to  happen 
to  the  incisors,  the  canines,  and  the  palatine  roots  of 
the  superior  molars.  But  after  the  complete  devel- 
opment of  the  teeth,  there  is  no  excuse  for  an  acci- 
dent of  this  kind,  for  then  there  is  an  abrupt  con- 
traction of  the  canal  near  the  point  of  the  root,  which 
may  always  be  detected  by  a  careful  introduction  of 
the  instrument. 

The  decayed  and  pulp-cavities  and  the  canal  all 
being  thus  prepared,  are  now  ready  to  receive  the 
filling.  For  filling  the  root,  there  are  several 
methods,  one  of  which  is,  to  prepare  small  strips  of 
gold,  of  two  or  four  thicknesses  of  foil;  take  these 
on  the  point  of  an  instrument,  and  pack  them  into 
the  root,  in  successive  folds,  till  the  canal  is  full. 
Another  method  is,  to  take  small  portions  of  gold, 
and  pack  them  in,  one  on  another,  till  the  canal  is 
full.  Another  is,  to  take  strips  of  from  two  to  four 
thicknesses,  and  from  one  to  two  lines  wide,  and  roll 
them  on  a  fine  broach  in  such  a  manner  as  to  make 
a  cone-shaped  block,  a  little  longer  than  the  depth 
of  the  canal  to  be  filled,  and  of  the  same  taper;  quite 
a  number  of  these  blocks  will  be  required  for  any 


328  PULP-CAVITIES. 

given  case,  of  various  sizes,  lengths,  and  densities. 
The  longest,  largest,  and  least  dense  should  be  first 
used,  the  last  requiring  to  be  of  less  size  and  greater 
density.  These  cones  may  be  made  as  dense  as 
desirable  by  rolling  them  firmly  between  the  thumb 
and  fingers,  after  having  taken  them  off  the  broach. 
They  are  then  introduced  with  the  plugging  pliers, 
and  passed  up  as  near  to  the  point  of  the  root  as  is 
consistent  with  safety.  In  some  instances  there 
is  danger  of  thrusting  them  through  the  point; 
and  in  order  to  prevent  this,  the  end  of  the  first 
block  introduced  may  be  made  so  large  that  it  will 
not  pass  through,  even  when  forced  up ;  or,  what  is 
probably  better,  a  very  small  round  pellet  of  gold 
may  be  forced  up  the  canal,  as  near  to  the  point  of 
the  root  as  admissible,  and  this  serves  as  a  founda- 
tion for  the  subsequent  portions  of  gold,  and  prevents 
them  from  passing  too  far  up.  The  cone-shaped 
blocks  may  be  introduced  and  consolidated  with  an 
instrument  of  the  same  general  form  as  the  canal, 
but  much  smaller.  This  kind  of  instrument  should 
be  made  of  untempered  steel,  though  some  operators 
make  them  of  whalebone,  to  prevent  breaking  off  in 
the  canal, — an  unnecessary  precaution,  since  no  skill- 
ful operator  would  ever  break'  off  a  low-tempered, 
well-polished,  properly-formed  steel  instrument  of  this 
kind.     After  a  block  is    placed   in  the  cavity,  the 


FILLING    PULP-CANALS. 


329 


instrument  is  thrust  in  by  its  side,  consolidating 
the  gold  to  the  side  of  the  cavity.  Thus  the  blocks 
are  successively  introduced  and  consolidated,  till  the 
canal  is  filled.  It  is  better  so  to  arrange  as  to  intro- 
duce the  last  portion  of  the  gold  near  the  centre  of 
the  canal,  rather  than  at  the  side.  The  last  blocks 
introduced  should  be  stiff  and  dense,  that  they  may 
be  thrust  in  with  considerable  force.  The  method  of 
filling  canals  at  present  employed  by  many,  is  in 
the  use  of  the  filling  instruments  invented  by  Dr.  C. 
Palmer,  represented  in  Fig.  91.     There  is  a  variety 


Fis.  91. 


in  size  and  somewhat  in  form,  so  that  in  all  positions 
they  will  readily  enter  the  canals  and  effectually 
consolidate  the  gold,  which  is  introduced  in  small 
cone-shaped  pellets,  loosely  rolled,  so  that  they  may 
be  thoroughly  condensed. 

Another  method  of  preparing  gold  for  filling  roots, 


330  PULP-CAVITIES. 

is  to  take  the  pure  metal,  and  roll  it  down  on  a 
good  rolling-mill  as  thin  as  possible,  keeping  it  well 
annealed ;  of  this  form  the  cones,  and  introduce 
them  as  already  directed.  Made  in  this  way,  they 
are  stiffer,  and  fill  up  much  more  rapidly  than  when 
made  of  foil.  They  are  to  be  condensed  in  the  same 
manner.  Where  the  canal  has  been  formed  with  a 
tapered  broach,  it  may  be  filled  with  a  gold  wire, 
made  of  the  same  size  and  taper  of  the  broach  ;  this 
wire  may  be  cut  off  at  the  orifice  of  the  canal,  or  left 
protruding  more  or  less  into  the  decayed  cavity,  and 
be  covered  up  with  the  filling.  When  a  lost  portion 
of  the  form  of  a  tooth  is  to  be  restored,  such  project- 
ing wires  may  be  made  very  valuable  as  anchorages. 
Some  other  substances  have  been  thought  quite  as 
suitable  for  filling  the  roots  of  teeth  as  gold.  Lead 
has  been  employed  for  this  purpose  ;  but  the  principal 
difficulty  with  this  is,  to  get  it  into  such  a  condition 
as  to  be  used  with  facility;  but,  if  as  completely 
introduced,  it  would  probably  answer  the  purpose 
quite  as  well  as  gold.  Dr.  F.  Peabody,  about  three 
years  ago,  described  a  method  of  filling  the  roots  of 
teeth  with  lead,  which  his  experience,  as  well  as  that 
of  some  others,  seems  to  indicate,  in  many  cases 
at  least  is  very  good.  It  consists  simply  in  forming 
the  canal  in  the  root,  slightly  tapering  from  the  pulp- 
chamber  to  its  termination ;  then  form  from  a  lead 


FILLING    PULP-CAXALS.  331 

rod  a  cylinder  or  cone  of  the  same  size  and  taper  as 
the  canal  in  the  root ;  let  this  be  driven  firmly  to  its 
place  in  the  root ;  the  rod  may  now  be  cut  off,  leaving 
a  slight  projection  from  the  entrance  to  the  canal ;  by 
this  the  orifice  can  be  very  perfectly  closed  ;  then  the 
pulp-chamber  and  cavity  of  decay  may  be  filled  in  the 
usual  manner.  Tin  foil  is  also  used,  and,  under 
favorable  circumstances,  with  success.  Gutta-percha, 
dissolved  in  chloroform,  is  used  to  some  extent,  and, 
it  is  claimed,  with  decidedly  good  results.  It  is  pre- 
pared of  such  consistence  as  to  be  readily  pumped 
into  even  the  smallest  canals  by  a  little  piston  made 
by  wrapping  cotton  upon  a  fine  broach ;  and,  after 
having  the  canal  prepared,  it  is  filled  by  forcing  the 
gutta-percha  solution  in  with  the  ajipliance  referred 
to.  Some  experiments,  too,  have  been  made  with 
plaster  of  Paris  and  similar  substances,  for  filling 
roots  and  pulp-cavities,  but  with  rather  uncertain  suc- 
cess— some  claiming  instances  of  success,  and  others 
reporting,  in  every  instance,  failure ;  so  that  there  are 
not  sufficient  data  to  warrant  the  adoption  of  plaster 
or  any  similar  substance  in  practice. 

In  cases  in  which  there  is  liability  to  irritation, 
the  operation  of  filling  a  root  is  quite  enough  for  one 
sitting ;  and  in  any  case,  not  more  than  three  roots 
should  be  filled  at  one  time.  The  filling  of  a  large 
pulp-cavity  will  occupy  one  sitting,  and  that  of  the 


332  PULP-CAVITIES. 

decayed  cavity  another.  When  a  respite  is  thus  had 
between  the  filling  of  the  pulp-cavity  and  that  of  the 
decayed  cavity,  the  former  should  be  filled  with 
Hill's  stopping  or  gutta-percha,  so  that  no  moisture 
may  penetrate  it ;  and  then  when  the  latter  part  of 
the  filling  is  to  be  introduced,  it  will  proceed  as 
though  there  had  been  no  interruption.  From  one  to 
four  days  should  intervene  between  the  different 
divisions  of  the  operation.  The  filling  of  the  decayed 
cavitv  is  to  be  performed  accordino:  to  the  directions 
already  given.  When  inflammation  ensues  after  an 
operation  of  this  kind,  recourse  is  had  to  the  treat- 
ment already  described  for  preventing,  counteracting, 
or  reducing  inflammation. 

Some  experiments  have  been  made  to  test  the 
effect  of  restoring  the  parts  to  health,  forming  a  cica- 
trice at  the  point  of  the  root,  cleansing  this  out,  filling 
the  pulp-cavity  and  the  cavity  of  decay,  and  leaving 
the  canal  unfilled;  and  it  is  maintained  that  this 
method  will,  in  favorable  cases,  answer  the  purpose 
quite  as  well  as  that  of  filling  the  root,  and  incur  less 
risk.  The  treatment  will  be  such  as  already  de- 
scribed for  the  restoration  of  diseased  roots ;  all  dis- 
charge through  it  must  be  suppressed,  and  all  foreign 
substances  liable  to  decomposition  removed  from  the 
canal,  so  that  there  may  be  a  complete  restoration 
before  it  is  closed. 


FILLING   PULP-CAXALS.  333 

Oftentimes,  when  a  tooth  has  been  filled  without 
filling  the  roots  and  pulp-chamber,  if  the  pulp  be 
dead,  or  if  the  pulp  afterward  dies,  the  chamber 
becomes  the  receptacle  of  a  very  vitiated  and  acrid 
material,  the  retention  of  which  will  almost  invariably 
produce  irritation.  In  all  such  cases,  an  opening 
should  be  made  for  the  escape  of  the  offensive  matter. 
This  is  done,  if  the  filling  is  not  to  be  removed,  by 
passing  a  small  drill  into  the  pulp-chamber  or  canal, 
just  above  the  filling,  as  close  as  possible.  The  handle 
of  the  drill  should  be  depressed,  so  as  to  give  the 
opening  a  downward  inclination  from  within  outward, 
and  thus  favor  the  escape  of  any  secretion. 

In  the  superior  molars,  this  opening  may  be  made 
through  the  masticatory  surface ;  it  may  sometimes 
be  in  the  depressions  on  the  crown  surface,  even 
thou2;h  there  be  no  fillins:.  In  incisors,  it  is  made 
through  the  palatine  portion  of  the  crown.  It  is 
better,  however,  in  all  cases,  to  make  an  opening  of 
this  kind  through  the  neck  of  the  tooth,  just  under 
the  free  margin  of  the  gum,  since  here  foreign  sub- 
stances are  not  so  liable  to  be  crowded  into  it  as 
where  it  is  through  the  masticatory  surface.  In 
cases  in  which  it  is  obvious  at  the  time  of  filling  the 
tooth  that  such  an  opening  will  be  required,  it  is 
better  to  make  it  before  the  filling  is  introduced,  as 
follows  :  first,  prepare  the  decayed  and  pulp-cavities 


% 


334  PULP-CAVITIES. 


for  filling;  then  drill  throngh  the  neck  of  the  tooth 
into  the  canal,  to  the  extreme  part  of  the  pulp- 
chamber  ;  and  finally  introduce  into  this  hole,  its 
entire  depth,  a  piece  of  smooth  steel  wire,  such  as 
will  closely  fit,  leaving  it  exposed  through  the  de- 
cayed cavity — and  if  it  is  not  enough  exposed  when 
introduced,  the  tooth-bone  may  be  cut  away  about  it, 
till  it  is  fully  exposed,  when  the  decayed  and  pulp- 
cavities  are  filled  in  the  usual  manner,  and  condensed 
solidly  against  the  wire.  After  the  filing  is  finished, 
the  wire  is  withdrawn,  leaving  a  smooth,  continuous 
opening  for  the  escape  of  any  secretion  that  may 
collect  within.  When  the  opening  into  the  canal  is 
not  made  till  after  the  tooth  is  filled,  there  is  liable 
to  be  a  space  between  it  and  the  filling  that  will 
receive  and  retain  fetid  matter,  which  may  become 
very  offensive.  This  method  of  treatment  is,  however, 
always  to  be  deprecated,  and  should  never  be  em- 
ployed except  as  a  last  resort,  or  in  cases  where  it  is 
impossible  to  command  the  time  and  opportunity  for 
the  proper  treatment ;  and  even  then  it  is  better  to 
make  the  opening  and  entrance  into  the  chamber  and 
canal  just  as  though  it  were  to  receive  immediate 
treatment ;  for  in  a  great  many  instances  the  oppor- 
tunity for  that  may  soon  occur. 


DENTAL    PERIOSTITIS.  335 


DExNTAL    PERIOSTITIS. 


This  affection  of  the  investing  membrane  of  the 
roots  of  the  teeth  is  of  frequent  occurrence  after  the 
death  of  the  pulp,  but  rarely  if  ever  before.  Inflam- 
mation of  this  tissue,  in  its  manifestation,  is  modified 
by  the  anatomical  structure  of  the  parts. 

Whether  there  be  two  membranes  in  the  alveolar 
sockets,  the  one  lining  the  walls  of  these,  and  the 
other  investing  the  roots  of  the  teeth,  is  not  a  matter 
of  importance  so  far  as  the  nature  and  treatment  of 
this  affection  is  concerned.  This  condition  of  the  den- 
tal periosteum  is  induced  by  such  irritating  causes  as 
would  produce  inflammation  in  other  tissues. 

The  first  indication  of  approaching  difficulty  in  this 
tissue  is  a  sense  of  slight  fullness,  which  invites  con- 
tact, and  even  pressure  from  the  opposing  teeth — 
such  pressure  affording  a  rather  pleasurable  sensation 
and  seeming  relief. 

This  condition  is  brought  about  by  determination 
of  blood  to  the  part,  and  the  surroundings  being  such 
as  to  prevent  free  expansion  to  the  capillaries,  and 
other  small  vessels  ramifying  this  membrane,  these 
walls  are  pressed  upon  in  proportion  to  the  force  of 
this  determination. 

This  effort  at  expansion  will  occasion,  especially 
in  those  teeth  having  very  conical  roots,  quite  a  per- 


336  DENTAL    PERIOSTITIS. 

ceptible  elongation,  and  this  more  particularly  occurs 
"when  active  inflammation  superA^enes,  which  is  the 
sequence  of  the  state  of  irritation  to  which  reference 
has  just  been  made. 

After  active  inflammation  has  occurred,  pressure 
or  percussion  upon  the  affected  tooth  usually  causes 
great  pain, — to  such  an  extent  that  sometimes  the 
slightest  contact  even  by  the  tongue  is  intolerable. 

This  condition  varies  much  in  desrree  in  different 
cases,  dependent  largely  upon  the  predisposition  and 
susceptibility  to  exciting  causes  of  irritation  and 
inflammation,  together  with  the  character  of  these 
exciting  causes,  whether  concentrated  in  action  to  a 
mere  point,  or  more  extensive  in  their  sphere  of 
operation. 

Oftentimes  only  a  very  small  portion  of  the  i^eri- 
osteum  of  a  tooth  will  be  affected ;  it  may  be  confined 
to  the  immediate  vicinity  of  the  point  of  the  root,  or 
to  one  side,  or  to  the  periosteum  near  the  margin  of 
the  alveolus  and  the  border  of  the  gum. 

Indeed,  so  circumscribed  is  this  affection  often 
found,  that  the  periosteum  on  one  side  of  a  root  will 
pass  through  all  the  successive  stages  of  inflamma- 
tion to  suppuration  and  destruction,  without  that 
upon  the  opposite  side  having  undergone  anything 
more  than  a  slight  irritation,  if  even  that.  In  such 
cases  the  vitality  has  sufficient   power  to  hold  the 


I 


DENTAL    PERIOSTITIS.  337 

disease  at  bay,  and  confine  it  to  the  immediate  point 
of  attack. 

When  there  is  a  systemic  predisposition,  the  local 
exciting  causes  will  sooner  and  more  vigorously 
attack.  Always  when  the  pulp  of  a  tooth  is  devital- 
ized, the  periosteum  is  more  liable  to  disease,  and 
perhaps  for  several  reasons.  In  almost  all  cases 
there  are  irritants  at  hand  that  did  not  exist  before ; 
and  the  periosteum  is  either  enfeebled,  and  conse- 
quently less  resistant,  or  the  demand  upon  its  func- 
tion greater  than  before,  in  view  of  its  being  the 
medium  of  connection  between  the  normally  vital 
tissue  and  that  which  is  devitalized,  or,  at  best,  its 
life  very  much  impaired ;  and  when  the  latter  condi- 
tion exists,  the  nourishment  received  by  the  cemen- 
tum  and  dentine  is  wholly  through  the  periosteum. 
In '  these  facts  doubtless  are  to  be  found  the  cause 
of  the  greater  susceptibility  of  the  dental  periosteum 
to  disease  after  than  before  the  death  of  the  pulp. 

The  exciting  causes  of  this  affection  are  to  be 
found  in  the  acrid  debris  of  the  dead  and  decaying 
pulps  of  the  teeth,  passing  either  in  a  fluid  or  gase-- 
ous  state  through  the  foramen  at  the  point  of  the 
root,  and  there  coming  in  contact  with  the  perios- 
teum, and  in  various  deposits,  calcareous  and  others, 
insinuated  beneath  the  margin  of  the  gum,  encroach- 
ing upon  and  irritating  the  periosteum. 


338  DENTAL   PERIOSTITIS. 

It  is  also  sometimes  occasioned  by  an  extension  of 
disease  from  some  other  point.  As  an  illustration  of 
this,  in  susceptible  cases,  the  periosteum  of  one  tooth 
may  become  affected  by  the  action  of  some  local  irri- 
tant, and  two  or  more  of  its  neighbors  become  affected 
by  extension  of  the  inflammation. 

Some  medicinal  agents  act  specifically  upon  the 
dental  periosteum,  inducing  a  very  painful  condition, 
thickening  of  the  tissue,  and  elongation  of  the  teeth. 

Mercurials  present  an  illustration  of  this  class  of 
agents.  The  precise  condition  produced  in  the  den- 
tal periosteum  in  mercurial  ptyalism  is  perhaps  not 
clearly  comprehended.  It  is  more  than  simple  in- 
flammation. It  is  not  modified  or  controlled  by  the 
same  remedial  treatment.  It  attacks  the  periosteum 
of  living  teeth  as  readily,  and  with  quite  as  much 
violence,  as  of  those  which  are  devitalized.  Alveolar 
abscess  is  not  a  common  result  of  this  affection  of  the 
periosteum. 

Treatment. — The  treatment  of  dental  periostitis,  in 
its  details,  will  be  governed  by  the  attendant  condi- 
tions, such  as  systemic  predispositions,  the  vital  force, 
and  the  local  causes,  and  their  peculiarities. 

Systemic  treatment  should  have  for  its  object  the 
removal  or  counteracting  of  predispositions,  and  the 
abatement  of  the  determination  of  blood  to  the  part 
in  question,  by  inviting  it  to  other  parts,  by  their 


DENTAL    PERIOSTITIS.  339 

stimulation,  and  by  introducing  into  the  system  such 
agents  as  will  tend  to  allay  excitement  in  the 
afifected  part,  and  induce,  so  far  as  possible,  an  equi- 
librium of  circulation  throughout  the  system. 

The  local  treatment  must  also  be  wisely  and  faith- 
fully attended  to.  The  principle  applicable  to  the 
treatment  of  inflammation  in  any  tissue  is  that  to  be 
employed  here.  It  will  be  remembered,  however, 
that  there  are  many  medicinal  agents  which  possess 
very  desirable  properties  that  are  still  totally  ineffi- 
cient, because  of  a  want  of  adaptation.  We  have, 
however,  at  our  command  some  veiy  efficient  reme- 
dial agents  for  the  treatment  of  this  affection,  and  the 
list  is  being  constantly  enlarged. 

We  propose  here  to  consider  rather  the  principles 
involved  in  the  treatment  than  details  for  special 
cases. 

The  causes  producing  and  influencing  the  disease 
should  always  be  fully  apprehended,  immediately 
after  which  the  following  points  should  receive  atten- 
tion :  First,  remove  all  irritants ;  this  will  embrace 
the  removal  of  the  dead  pulp,  and  all  the  debris  from 
its  chamber,  and  from  the  canal  in  the  root  or  roots, 
and  rendering  them  perfectly  free  from  all  ofl'ensive 
material,  and  keeping  them  so ;  and  the  removal  of 
all  deposits  that  may  be  upon  the  teeth,  especially 
those  that  may  encroach  upon  the  gum,  or  the  alve- 


340  DENTAL   PERIOSTITIS. 

olus  and  periosteum  at  or  beyond  the  neck  of  the 
tooth ;  also  the  removal  of  all  injurious  and  useless 
teeth  and  roots  in  the  Ticinity. 

Secondly,  relieve  the  congestion  of  the  affected 
part,  in  some  or  all  of  the  following  ways  :  either  by 
systemic  influence,  as  already  suggested,  or  by  coun- 
ter-irritation, producing  determination  to  a  neighbor- 
ing part,  and  thus  relieving  the  affected  part,  or  by 
depletion  from  the  gum  immediately  opposite  the 
seat  of  the  affection. 

Counter-irritation  may  be  effected  by  scarifying 
the  gum,  or  by  the  application  of  some  irritating 
agent,  such  as  tincture  of  capsicum,  tincture  of 
iodine  and  cantharides.  An  excellent  preparation  of 
the  latter,  denominated  cantharidal  collodion,  is  very 
effective.  This  preparation  when  applied  to  the 
gum  acts  jDromptly  and  efficiently  in  almost  every 
case  of  acute  dental  periostitis  ;  it  produces  desqua- 
mation upon  the  surface  of  the  mucous  membrane 
where  it  is  applied. 

Counter-irritation  may  be  produced,  also,  by  mak- 
ing a  deep  incision  in  the  gum  opposite  the  tooth 
affected,  and  introducing  a  little  flock  of  floss  or 
cotton,  saturated  with  creosote,  which  is  to  be  kept 
in  place  till  the  inflammation  of  the  periosteum  is 
allayed,  which  will  be  effected  in  from  one  to  five 
days.     The  silk  or  cotton  should  be  changed  every 


DENTAL    PERIOSTITIS.  •  341 

day  till  the  restoration  of  the  tooth  to  health  is 
effected,  when  it  is  to  be  removed,  and  the  wound 
permitted  to  heal.  Mild  stimulating  applications  to 
the  gums  in  the  immediate  vicinity,  to  increase  the 
circulation,  will  in  some  cases  be  quite  sufficient. 
A  vapor  bath,  or  warm  water  applied  to  the  part,  is 
often  beneficial ;  and  in  some  cases  a  continued  appli- 
cation of  cold,  by  means  of  ice-water,  will  arrest  in- 
flammation of  the  periosteum. 

The  tincture  of  aconite-root  is  a  valuable  local 
application.  It  is  a  powerful  sedative  and  antiphlo- 
gistic remedy.  This,  with  equal  parts  of  tincture  of 
opium  and  chloroform,  constitutes  a  A^ery  valuable 
local  remedy  for  periostitis.  It  may  be  applied  by 
occasionally  moistening  the  gum  with  it,  or  by 
placing  on  the  gum,  opposite  the  seat  of  the  affec- 
tion, a  small  pad  of  bibulous  paper  or  lint,  moistened 
with  the  preparation,  which  may  remain  from  three 
to  five  minutes.  This  may  be  repeated  as  occasion 
may  require ;  usually,  however,  from  one  to  three 
applications  will  be  sufficient. 

Depletion  with  many  is  a  favorite  method  of  treat- 
ment, and  is  often  productive  of  very  good  results. 
Two  or  three  methods  of  accomplishing  this  are  em- 
ployed. Simple  scarification  of  the  gum,  cutting  it 
more  or  less  deeply,  will  secure  sufficient  hemor- 
rhage, especially  if  the   gums    are   quite   vascular; 


342  DENTAL   PERIOSTITIS. 

when  this  fails,  cupping,  or  the  artificial  leech,  may 
be  employed ;  but  the  natural  leech  is  the  most  effi- 
cient means  of  local  depletion  in  this  treatment ;  and 
every  dentist  should  always  have  these  at  command, 
and  be  familiar  with  their  use.  The  application  of 
a  leech,  in  very  many  cases,  will  in  a  short  time 
subdue  the  most  violent  attack  of  acute  periostitis. 

In  the  treatment  of  this  affection,  hypodermic 
injections  give  promise  of  most  desirable  results  ;  for 
this  purpose  the  solution  of  morphine  or  tincture  of 
opium,  from  ten  to  twenty  drops,  may  be  injected, 
with  a  proper  syringe,  beneath  the  mucous  mem- 
brane, when  the  pain  will  be  found  to  subside  in  a 
few  moments,  and  the  severest  symptoms  be  abated 
in  a  few  hours. 

In  all  cases  of  periostitis,  the  sooner  it  can  be 
brought  under  proper  treatment  after  the  attack,  the 
more  easily  will  it  be  subdued.  In  cases  of  longer 
standing,  where  the  affection  has  assumed  a  chronic 
form,  the  membrane  more  or  less  thickened  and 
indurated,  and  a  persistent  soreness  of  the  tooth 
affected,  heroic  and  persevering  treatment  will  be  re- 
quired to  overcome  the  difficulty ;  in  the  great  major- 
ity of  cases,  however,  the  result  is  the  formation  of 
alveolar  abscess,  rather  than  the  condition  just  re- 
ferred to,  a  description  and  treatment  of  which  will 
next  receive  consideration. 


ALVEOLAR    ABSCESS.  343 

ALVEOLAR   ABSCESS. 

When  inflammation  occurs  in  the  periosteum  to 
the  extent  that  the  structural  character  of  the  tissue 
can  no  longer  be  maintained,  then  disintegration  be- 
gins in  it,  and  the  surrounding  tissue  also,  so  far  as 
it  may  be  involved.  When  the  condition  arrives  in 
which  the  life  action  ceases,  the  tissue  at  once  begins 
to  undergo  solution,  and  in  addition  to  this,  the 
pabulum  or  nutrient  material,  brought  into  the  dis- 
eased territory,  is  for  the  most  part  vitiated,  its 
nutrient  quality  destroyed,  and  it  is  converted  into 
debris,  except  that  from  it,  under  favorable  circum- 
stances, coagulated  lymph  is  formed,  which  consti- 
tutes what  has  been  so  generally  denominated  the 
sac,  and  by  some  the  pus-secreting  sac,  and  by  others 
the  pyogenic  membrane. 

Now,  strictly,  it  is  not  any  of  these,  but  is  simply 
a  mass  of  coagulated  lymph,  varying  in  quantity, 
when  it  exists  at  all,  from  a  little  shred  or  bleb,  that 
is  but  little  more  than  visible,  to  a  mass  as  large  as 
the  tooth  to  which  it  is  attached.  As  to  its  location, 
it  varies ;  sometimes  it  is  embraced  by  and  fills  up 
the  space  between  the  roots  of  the  molars,  either 
superior  or  inferior.  In  some  cases  it  is  merely  an 
irregular  mass  attached  to  the  end  of  the  root  about 
which  the  disease  is ;  in  other  cases  it  will  cover  a 


344 


ALVEOLAR   ABSCESS. 


large  part  of  the  surface  of  the  root  or  roots  involved. 
The  accompanying  illustration  (Fig.  92)  represents 


Fiff.  92. 


the  position  of  the  lymph  mass  on  the  roots  of  differ- 
ent teeth.  It  will  be  more  or  less  firmly  attached 
according  to  the  extent  of  the  disintegration  of  the 
periosteum — being  less  adherent  when  there  is  the 
greater  destruction  of  the  tissue.  A  portion  Avill 
sometimes,  upon  the  removal  of  the  tooth,  remain  in 
the  socket,  with  some  attachment,  though  usually 
but  slight,  to  the  walls ;  this,  however,  is  not  its 
usual  place  of  lodgment  and  attachment.  The  density 
of  this  lymph  mass  varies  in  different  cases.  Some- 
times it  is  quite  dense,  firm  and  resistant ;  at  other 
times  so  soft  and  flabby  as  hardly  to  support  its  own 
weight.  Now,  that  this  substance  is  instrumental 
in,  or  has  anything  to  do  with,  secreting  or  forming 
pus,  or  the  material  discharged  from  an  alveolar 
abscess,  is  not  established  nor  warranted  by  deduc- 
tion nor  by  fact. 


ALVEOLAR   ABSCESS.  345 

Now,  the  question  occurs,  what  is  the  object  of 
this  product?  It  may,  in  the  first  place,  be  regarded 
as  an  abortive  effort  for  the  repair  of  lost  tissue,  and, . 
in  the  second  place,  the  encystment  of  the  disease- 
producing  agent.  Neither  of  these,  however,  can  be 
accomplished.  Repair  cannot  take  place  so  long  as 
the  disease-producing  agent  is  present;  and  the  cha- 
racter of  the  agent  or  agents,  and  the  anatomical 
structure  of  the  parts,  preclude  encystment.  The 
local  agents  that  occasion  alveolar  abscess  may  be  in 
form  either  solid,  soft-solid,  fluid,  vapor  or  gas. 
Some  of  these  could  not  be  encysted  in  any  anatomi- 
cal structure,  and  none  of  them  can  be  in  the  tooth 
socket.  This  lymph  mass  is  not  only  of  no  service 
in  respect  to  reparation,  but  is  a  real  obstacle  to  the 
proper  accomplishment  of  that  process.  This  is  fully 
recognized  in  all  the  proposed  plans  of  remedy ;  its 
removal  is  always  regarded  as  an  important  factor  in 
the  treatment. 

The  character  of  the  discharge  from  alveolar  ab- 
scess differs  greatly  in  different  cases,  and  somewhat 
at  different  periods  of  the  same  case.  It  somethnes 
consists  of  pure  or  laudable  pus  ;  this  is  of  a  yel- 
lowish-white color,  opaque,  inodorous,  sweetish  taste, 
and  of  a  creamy  consistence.  In  the  majority  of 
cases  it  varies  from  this,  however,  exhibiting  less  the 
character  of  pus,  with  diminution  of  pus-corpuscles, 


346  ALVEOLAR    ABSCESS. 

and  an  increase  of  vitiated  ichorous  fluid,  in  whicli 
sometimes  pus-corpuscles  are  not  found  at  all,  with 
an  acridity  so  great  as  to  excoriate  living  tissue 
whenever  it  comes  in  contact  with  it. 

Usually,  when  pure  pus  is  secreted,  coagulated 
lymph  will  be  found  most  abundant;  and,  on  the 
other  hand,  when  a  highly-vitiated,  acrid  discharge  is 
found,  there  will  be  almost,  if  not  an  entire  absence 
of  the  lymph  mass. 

The  character  of  the  discharge  is  modified  by  the 
systeniic  condition,  by  the  tissue  disintegrated,  and 
by  the  character  of  the  local  irritants  ;  and  it  can 
only  be  changed  by  a  modification  of  the  first  of 
these,  and  the  removal  of  the  latter. 

The  size  of  the  abscess  cavity  varies  in  different 
cases  ;  in  some  it  is  quite  small,  involving  a  very 
little  territory  in  the  immediate  vicinity  of  the  point 
of  irritation  ;  in  others  it  becomes  enlarged,  some- 
times to  twice  the  size  of  the  tooth  about  which  it  is. 
This  difference  arises  from  the  varying  severity  of 
the  disease,  and  the  peculiar  susceptibility  of  the 
parts. 

Usually  the  cavity  has  attained  its  full  size  before 
the  evacuation  of  the  pus  ;  and  if  this  is  benign, 
little  or  no  disintegration  takes  place  afterward  ;  but 
it  may  be  otherwise  if  the  secretion  is  acrid. 

In  an  abscess  rapidly  formed,  there  is  very  con- 


ALVEOLAR   ABSCESS.  347 

siderable  pressure  by  the  contents  upon  the  walls  of 
the  cavity  while  it  is  closed,  and  this  is  always  the 
cause  of  pain,  which  in  many  instances  is  very  severe. 
So  soon  as  an  opening  is  effected,  and  the  tension 
relieved,  the  pain  in  a  great  measure  ceases. 

There  are  various  directions  through  which  openings 
are  made  for  the  escape  of  the  pus.  Sometimes  the  dis- 
charge is  through  the  root,  sometimes  from  between 
the  tooth  and  alveolus,  and  at  other  times  directly 
through  the  alveolus  and  gum.  There  are  occasional 
cases  in  which  the  discharge  will  be  at  a  very  con- 
siderable distance  from  the  point  of  secretion  ;  but  in 
such  cases  it  always  follows  some  natural  avenue 
that  affords  a  fjxcility  for  its  passage,  as,  for  instance, 
along  a  suture.  There  are  cases  recorded  where  the 
issue  from  an  abscess  of  the  central  incisor  was  near 
the  posterior  portion  of  the  hard  palate,  and  in  these 
the  channel  of  the  pus  lay  along  the  suture  of  the 
palate  bones.  Sometimes  the  opening  from  an  abscess 
of  the  first  or  second  molar  will  be  opposite  the 
bicuspids  on  the  buccal  portion  of  the  gum.  Alveolar 
abscess  is  exceedingly  variable  in  character,  according 
to  the  constitutional  peculiarities  and  susceptibilities 
of  the  patient,  the  condition  of  the  parts  immediately 
adjacent,  and,  to  some  extent,  the  cause  which  has 
produced  it.  In  a  good  constitution,  after  an  abscess 
is  formed,  it  will  discharge  healthy  pus.     Occasion- 


348  ALVEOLAR    ABSCESS. 

ally,  yet  very  seldom,  does  nature  alone  effect  a  per- 
manent cure.  In  constitutions  of  a  cachectic  diathesis, 
alveolar  abscess  is  liable  to  constant  discharge  of  an 
unhealthy  pus,  or  purulent  acrid  matter,  and  the  parts 
about  it  are  usually  in  a  diseased  condition. 

The  cases  in  which  alveolar  abscess  is  most  likely 
to  occur  are  those  of  a  manifest  inflammatory  dia- 
thesis, or  those  in  which  there  is  considerable  local 
inflammation,  from  some  local  exciting  cause.  In 
the  cases  of  constitutional  predisposition,  the  abscess 
after  a  time  assumes  a  chronic  character,  constantly 
secreting  and  discharging  pus,  but  does  not  usually 
cause  much  pain,  though  the  tooth  from  which  it  pro- 
ceeds will  experience  some  soreness  and  an  uneasy 
sensation.  In  the  acute  forms  of  it,  however,  there 
will  be  intense  pain.  In  some  cases  an  abscess  will 
be  formed  without  much  irritation  of  the  surrounding 
parts,  while  in  others,  irritation  and  inflammation 
will  extend  to  parts  more  remote,  especially  if  there 
are  active  irritating  agents  at  work. 

Treatment. — The  treatment  of  alveolar  abscess  will 
be  governed  by  the  constitution  of  the  patient  and 
the  condition  of  the  part  affected ;  a  case  of  recent 
origin  will  yicdd  much  more  readily  than  one  of  long 
standing.  When  a  case  has  assumed  the  chronic 
form,  and  the  surrounding  parts  have  become  impli- 
cated   in    the    diseased    condition,    a   restoration  to 


TREATMENT    OF    ALVEOLAR    ABSCESS.  349 

health  is  often  very  difficult.  In  the  earlier  periods 
of  the  profession,  the  removal  of  alveolar  abscess 
was  thought  to  be,  as  a  general  thing,  wholly  imprac- 
ticable. But  by  the  treatment  now  employed,  this 
a'ffection  is  readily  eradicated,  unless  the  parts  in 
the  immediate  vicinity  are  very  much  involved.  In 
some  cases  the  accumulation  on  the  point  of  the  root 
is  very  large,  and  absorption  has  taken  place,  to 
accommodate  it ;  in  such  instances,  this  being  de- 
stroyed, the  space  occupied  by  it  will  be  filled  up 
with  a  healthy  tissue.  In  young  persons,  when  an 
abscess  is  formed  on  the  point  of  a  root,  especially  in 
the  single-root  teeth  of  the  superior  maxilla,  the  dis- 
charge is  frequently  through  the  tooth,  in  conse- 
quence of  the  large  size  of  the  foramen  at  the  point 
of  the  root;  and  generally,  in  such  cases,  the  local 
treatment  may  be  made  through  the  canal.  Some- 
times the  discharge  is  between  the  root  and  the  wall 
of  the  alveolus.  More  often,  however,  especially  in 
persons  after  complete  development,  the  discharge  is 
through  the  alveolus  and  the  soft  parts  to  the  sur- 
face, by  the  shortest  course. 

When  an  alveolar  abscess  is  influenced  by  any 
constitutional  derangement,  general  treatment  must 
be  resorted  to,  such  as  the  condition  indicates.  The 
local  treatment  always  demanded  is  such  as  will 
break  up  and  destroy  the  accumulated  lymph  mass. 


350  ALVEOLAR    ABSCESS. 

This  is  effected  either  by  surgical  or  therapeutic 
treatment,  and  frequently,  in  chronic  cases,  by  both 
together,  but  in  the  great  majority  of  acute  cases  thera- 
peutic treatment  alone  will  be  sufficient.  In  order  to 
break  up  an  abscess  by  an.  operation,  it  must  be  easy 
of  access  ;  and  it  is  A^ery  seldom  that  an  operation  of 
this  kind  can  be  performed  through  the  root  of  a 
tooth ;  but,  fortunately,  in  almost  all  those  cases 
where  the  discharge  is  through  the  root,  therapeutic 
treatment  alone  will  answer  the  purpose.  When  the 
point  of  discharge  is  on  the  gum  opposite  the  accumu- 
lation on  the  root,  a  sharp-pointed  bistoury  should  be 
used,  and  the  cannl  of  discharge  sufficiently  opened 
to  admit  the  free  use  of  the  instrument  at  the  seat  of 
the  disease.  Then  the  lymph  mass  should  be  dis- 
sected from  the  point  of  the  root,  and  removed  as 
completely  as  possible.  After  this,  if  the  case  is  a 
favorable  one,  nature  may  be  left  to  accomplish  the 
work,  in  which  case  the  detached  material  will  be 
thrown  off,  healthy  granulations  developed,  and  the 
parts  restored  to  complete  health.  In  other  cases, 
however,  after  an  operation,  nature  unaided  will  not 
complete  the  cure ;  but  such  therapeutic  treatment 
must  be  resorted  to  as  the  circumstances  seem  to 
require.  In  some  cases  the  opening  through  the 
alveolus  will  require  to  be  enlarged;  and  this  part 
of    the    operation   requires   great    care.     All    loose 


TREATMENT    OF   AEVEOLAR   ABSCESS.  351 

particles  of  bone  should  be  removed  from  the  open- 
ing, since,  if  permitted  to  remain,  they  would  produce 
irritation,  and  tend  to  increase  the  difficulty. 

When  the  therapeutic  treatment  is  applied  through 
the  root,  the  canal  is  to  be  cleansed  of  all  foreign  and 
detached  matter,  and  opened  freely  through  to  the 
point ;  and  if  the  discharge  is  very  fetid,  some  disin- 
fectant should  be  used,  than  which  perhaps  nothing 
is  better  than  diluted  creosote,  since  a  fetid  condition 
keeps  up  irritation.  The  cleansing  of  the  root  may 
be  accomplished  by  injection  of  chloride  of  sodium ; 
after  which  the  agent  to  act  on  the  disease  at  its  seat 
is  to  be  introduced.  There  are  a  number  of  agents  used 
for  this  purpose,  the  chief  of  which  are  salicylic  acid, 
chloride  of  zinc,  nitrate  of  silver,  and  creosote,  the  first 
two  being  applied  in  the  solid  and  the  latter  two  in 
the  liquid  state — though  the  nitrate  may  be  employed 
in  the  solid  form.  (Use  of  salicylic  acid,  see  Ap- 
pendix E.)  The  method  of  using  the  chloride  of 
zinc  is  to  pass  it  in  small  portions  up  the  canal,  on  a 
piece  of  silk,  with  a  fine  probe,  entirely  through  the 
point  of  the  root,  which  process  should  be  repeated 
every  twenty-four  to  forty-eight  hours,  as  the  case 
may  indicate.  After  this,  during  two  or  three  days, 
floss  silk,  moistened  with  a  mild  solution  of  creosote 
and  tannin,  in  alcohol,  should  be  applied  daily ;  and 
then  clean  silk  or  cotton  may  be  worn  in  the  canal, 


352  ALVEOLAR    ABSCESS. 

changed  every  day,  for  three  or  four  days,  or  till  it  is 
manifest  that  there  is  no  longer  any  discharge,  and 
that  the  parts  are  in  a  healthy  condition.  If  nitrate 
of  silver,  in  solution,  or  creosote,  is  used,  a  piece  of 
floss  silk  should  be  moistened  with  it,  and  passed 
through  the  root  in  the  manner  already  described. 
The  nitrate  is  more  prompt  of  action  than  creosote, 
and  will  accomplish  a  specific  object  in  a  shorter 
time.  Either  of  these  solutions  may,  by  the  use  of 
the  syringe,  be  very  effectively  thrown  through  a 
root  in  the  following  manner :  Fill  the  orifice  of  the 
canal  with  gutta-percha;  drill  through  it  a  hole  large 
enough  to  receive  tightly  the  point  of  the  syringe ; 
and  then,  charging  with  the  solution,  inject  it 
through  the  root ;  in  cases  where  there  is  an  open- 
ing through  the  gum,  the  injection  may  be  forced 
round  through  this.  The  condition  of  the  parts  will 
indicate  how  long  this  kind  of  treatment  should  con- 
tinue. Ordinarily,  when  the  discharge  is  entirely 
through  the  gum,  the  bistoury  should  be  used  to 
enlarge  the  opening ;  or  in  some  cases  it  is  preferable 
to  use  the  "sea-tangle"  tent;  for  this  purpose  form  a 
plug  of  this  material,  in  size  to  fit  closely  into  the 
fistulous  opening,  where  it  should  be  placed  and  re- 
main for  twenty-four  to  forty-eight  hours.  "When 
saturated  with  moisture,  the  tent  expands  to  more 
than  double  its  size  when  in  the  dry  state.     Care 


TREATMENT    OF    ALVEOLAR    ABSCESS.  353 

should  be  exercised  lest  too  much  irritation  should 
be  produced  by  the  pressure ;  this,  however,  can  be 
easily  regulated.  In  many  cases  therapeutic  treat- 
ment alone  will  accomplish  the  object ;  and  when  the 
opening  is  large  and  direct,  the  therapeutic  agents 
may  be  introduced  through  it  directly  to  the  seat  of 
disease.  If  nitrate  of  silver,  in  solution,  or  creosote, 
is  used,  it  should  be  introduced  to  the  point  of  affec- 
tion on  a  pledget  of  cotton  or  floss  silk,  as  hereto- 
fore directed;  or  if,  as  is  preferable,  chloride  of 
zinc  or  nitrate  of  silver  in  solid,  it  should  be  passed 
through  the  opening  into  the  main  cavity.  This 
treatment  should  be  kept  up  till  the  indications  are 
fulfilled. 

In  the  treatment  of  abscess  of  the  inferior  maxilla, 
much  difficulty  is  often  experienced  from  a  want  of 
free  egress  for  the  secretion.  While,  in  the  supe- 
rior teeth,  the  pus  may  frequently  escape  through 
the  tooth  by  gravitation,  this  force  in  the  inferior  jaw 
increases  the  difficulty.  The  secretion  being  made 
at  the  bottom  of  the  socket,  it  remains  there,  and  is 
frequently  pent  up  till  it  finds  an  outlet  through  the 
gum,  somewhere  between  the  point  of  the  root  and 
the  neck  of  the  tooth.  It  is  in  many  instances  very 
difficult  to  get  an  opening  as  low  down  as  the  point 
of  the  root,  since  the  buccal  attachment  to  the  gum 
is  usually  quite  above  that  point,  particularly  in  the 


354  ALVEOLAR    ABSCESS. 

case  of  the  molars  and  bicuspids.  Very  seldom,  if 
ever,  can  the  coagulated  lymph  on  the  root  of  an 
inferior  tooth  be  destroyed  by  treatment  applied 
through  the  canal  of  the  root.  Some  are  accustomed 
to  make  a  vertical  incision  of  the  gum,  as  low  as  the 
point  of  the  root,  and  perforate  the  alveolus,  and 
treat  through  this  channel,  as  already  described. 
Owing  to  the  disadvantage  above  mentioned,  much 
more  energetic  treatment  is  necessary  to  attain  suc- 
cess with  an  abscess  of  the  inferior  than  with  that  of 
the  superior  teeth. 

In  the  great  majority  of  cases,  where  one-half 
or  more  of  the  periosteum  of  a  root  is  involved  in 
abscess,  the  indications  are  generally  supposed  to 
point  to  the  removal  of  the  tooth.  In  the  lower 
teeth,  a  very  serious  difficulty  occasionally  occurs 
from  abscess,  namely,  an  external  opening  and  dis- 
charge ;  and  in  all  cases  where  this  condition  has 
already  been  reached,  the  offending  tooth  should  be 
removed.  But  when  such  a  result  is  only  antici- 
pated, and  is  yet  contingent,  treatment  may  be  em- 
ployed to  avert  it ;  and  in  order  to  do  this,  a  deep 
and  free  incision  should  be  made  in  the  gum,  oppo- 
site the  affected  tooth,  and  poultices  applied  within ; 
and  where  there  is  external  swelling,  pressure  is 
recommended,  as  follows  :  Adjust  a  piece  of  thick 
sheet-lead  to  the  part,  and  make  the  pressure  on  this 


TREATMENT    OF    ALVEOLAR   ABSCESS.  355 

by  means  of  a  bandage  comprising  it  and  passing 
round  the  head.  It  is  supposed  that  this  application 
counteracts  the  gravitation  of  the  secretion,  pressing 
it  upward,  and  thus  inducing  it  to  seek  an  outlet  at 
some  more  desirable  point. 

In  many  cases  the  most  prompt  and  efficient  treat- 
ment consists  in  the  extraction  of  the  tooth  involved 
by  the 'abscess.  This  should  be  carefully  done,  that 
there  may  be  no  fracture  of  the  alveolus,  and  no 
laceration  of  the  gum.  After  the  tooth  is  removed, 
it  should  receive  the  following  treatment :  Remove 
from  the  root  or  roots,  with  the  proper  instrument, 
all  coagulated  lymph,  diseased  periosteum,  and  any 
foreign  substance  that  may  be  present.  The  cavity 
of  decay,  if  one  exists,  the  pulp-chamber,  and  canal 
in  the  root  or  roots,  should  all  be  perfectly  cleansed, 
formed,  and  filled  permanently.  This  will  occupy 
from  thirty  to  sixty  minutes.  This  part  of  the  work 
should  proceed  as  rapidly  as  is  consistent  with  tho- 
roughness. Immediately  after  the  removal  of  the 
tooth,  there  should  be  placed  in  the  socket  from 
which  it  was  removed  a  pledget  of  cotton  moistened 
with  some  preparation  that  would  be  acceptable  to 
the  part,  and  that  will  prevent,  so  far  as  may  be,  the 
coagulation  of  the  blood  while  the  tooth  is  out  of  the 
socket.  For  this  purpose  the  tincture  or  the  infusion 
of   calendula    (marigold)    has   been   used,   and   also 


356  ALVEOLAE,   ABSCESS. 

iiamamelis  virginica  (witch  hazel)  extract ;  both  of 
these  have  been  used  with  apparent  good  results. 
Some,  however,  prefer  to  use  nothing  of  the  kind  for 
this  purpose,  but  rather  permit  the  blood  to  coagu- 
late in  the  socket,  and  remove  just  before  inserting 
the  tooth. 

The  tooth  having  been  prepared  as  above  described, 
should  now  be  carefully  replaced  in  its  socket ;  the 
jaws  should  then  be  closed  firmly,  which  will  carry 
the  tooth  to  its  precise  position.  Ordinarily,  no 
stays  or  ligatures  will  be  required  to  hold  it  in 
position. 

Just  previous  to  the  replacement,  the  pledget  of 
cotton  will  be  removed,  and  any  debris  that  may 
be  found,  clots  of  blood,  and,  indeed,  any  and  every- 
thing that  does  not  properly  belong  to  the  part  as 
living  structure,  should  be  taken  away.  Usually, 
the  tooth  will  become  firmly  attached  within  a  few 
days.  This  mode  of  treatment  is  practicable  even 
when  the  fistulous  opening  has  been  formed  through 
the  cheek  to  the  external  surface. 

In  regard  to  the  treatment  of  alveolar  abscess, 
much  yet  remains  to  be  learned.  With  the  attain- 
ments thus  far  made  in  this  direction,  no  aspiring 
dentist  will  rest  satisfied,  though  in  the  hands  of  a 
few  it  has  made  great  progress  within  a  very  recent 
period. 


TREATMENT   OF   ALVEOLAR   ABSCESS.  357 

In  a  treatise  of  this  character  it  is  impracticable 
to  enter  into  the  details  of  the  pathology  of  this  affec- 
tion, or  very  minutely  into  the  rationale  of  its  treat- 
ment. A  thorough  knowledge  of  these  involves  a 
wide  range  of  pathological  knowledge. 


CHAPTER  X. 

PIVOT    TEETH. 

Whenever  the  crowns  of  the  anterior  teeth  have 
become  so  much  decayed  that  they  cannot  by  filling 
be  rendered  useful,  they  may,  under  favorable  cir- 
cumstances, be  supplied  by  artificial  crowns  con- 
structed on  the  roots.  For  the  successful  accom- 
plishment of  this  work,  the  following  conditions  are 
important : — 

First.  The  constitution  of  the  patient  should  be 
good. 

Second.  The  mouth  should  be  in  a  healthy  condi- 
tion, and  without  diseased  teeth  or  roots. 

Third.  The  teeth  should  be  free  from  calcareous 
deposits,  and  from  all  foreign  substances  liable  to 
induce  irritation  or  inflammation. 

Fourth.  The  attachment  of  the  teeth  should  be 
perfect  and  healthy. 

Fifth.  A  root  having  a  living,  healthy  pulp  is  to 
be  preferred  to  one  the  pulp  of  which  has  been  dead 
for  some  time. 

Sixth.  The  root  above  the  neck  should  be  sound. 


PIVOT    TEETH.  359 

Seventh.  The  root  should  occupy  a  correct  posi- 
tion in  the  arch.  Prior  constitutional  treatment  will 
often  be  required  where  there  are  unfavorable  con- 
ditions. 

The  roots  of  the  six  superior  anterior  teeth  are 
better  adapted  for  the  reception  of  artificial  crowns 
than  those  of  any  other  in  the  mouth.  The  roots  of 
the/irst  bicuspids  frequently  terminate  in  two  points, 
m  are  always  more  or  less  compressed,  so  that 
they  will  not  receive  a  pivot  large  enough  to  sustain 
a  crown ;  besides,  these  teeth  are  masticatory,  and 
crowns  pivoted  to  them  very  soon  become  loose  and 
useless.  The  roots  of  the  inferior  incisors  are  also 
compressed,  and  thus  subject  to  the  same  disability. 
Occasionally,  however,  pivot  crowns  are  attached  to 
the  roots  of  the  superior  bicuspids,  and  the  inferior 
incisors,  cuspids,  and  bicuspids.  But  in  order  that 
such  an  operation  shall  be  of  any  utility,  the  con- 
ditions must  be  favorable,  the  roots  with  as  little 
lateral  compression  as  possible,  in  a  very  sound  and 
healthy  state,  and  without  any  tendency  to  inflam- 
mation. 

The  preparation  of  the  root  for  the  reception  of 
an  artificial  crown  is  a  very  simple  process.  It  will, 
however,  be  somewhat  modified  by  the  kind  of  crown 
used,  and  the  method  of  attaching  it.  Ordinarily, 
the  first  step  is  to  remove  the  natural  crown,  or  any 


360 


PIVOT    TEETH. 


remaining  portion  of  it,  with  a  fine  saw  or  excising 
forceps.  Of  this  latter  instrument  there  are  various 
forms,  that  in  most  common  use  having  narrow 
transverse  edges,  closing  squarely  together,  as  repre- 
sented in  Fig.  93.     With  these  forceps  any  broken 

Fijr.  93. 


fragments  of  the  crown  can  be  removed  with  great 
facility.  Many  operators,  placing  their  edge  on  the 
neck  of  the  tooth,  are  accustomed  to  excise  with 
them  the  principal  part  of  the  crown  at  a  single  cut. 
This  method,  however,  is  objectionable,  since  it 
always  gives  too  great  a  jar  to  the  root,  and  is  liable 
to  loosen,  and  in  many  instances  to  fracture  it,  so  as 
to  unfit  it  for  the  reception  of  the  crown.  But  in 
every  case  in  which  an  artificial  crown  is  required, 
the  natural  crown  is  very  much  decayed,  and  in  this 
condition  is  very  readily  removed  with  excising  for- 
ceps, nipping  it  off  in  fragments,  beginning  where  it 
is  weakest  and  thinnest,  and  encroaching  on  it  till  it 


PIVOT    TEETH.  361 

is  all  cut  clown — at  least  as  far  as  the  forceps  are 
available.  Yet  care  is  necessary  even  in  this  manner 
of  using  the  forceps,  least  the  root  be  fractured  or 
too  much  jarred. 

After  such  excision  with  the  forceps,  the  root  is  to 
be  dressed  down  for  the  reception  of  the  crown,  with 
a  round  or,  better,  an  elliptical  file.  But  for  this 
operation  of  removing  a  crown,  a  very  fine,  smooth, 
narrow  saw,  set  in  a  frame    (Fig.   94),   is  in  some 

Yin.  94. 


respects  preferable  to  the  forceps,  it  being  less  liable 
to  injure  the  root  than  the  latter.  With  this  the 
crown  is  sawed  off  at  the  margin  of  the  gum,  leaving 
the  end  of  the  root  about  the  form  required  for  the 
reception  of  the  artificial  crown.  In  the  process,  the 
crown  being  sustained  by  the  fingers,  the  saw,  kept 
constanly  wet,  is  applied  to  the  tooth,  and  passed 
along  its  proximal  side  to  the  margin  of  the  gum, 
and  then  along  this  through  it,  cutting  it  off  at  right 
angles  with  its  axis.  After  the  crown  has  been  thus 
cut  off,  the  root  is  fitted  with  a  fine,  round  file, 
for  the  artificial  crown  ;  and,  ordinarily,  it  should  be 
dressed  at  right  angles  with  its  axis. 

At  this  stage   of  the  work,  if  the   pulp  remains 
alive,    it   should  be    removed ;    and    the    preferable 


362  PIVOT    TEETH. 

method  is  by  direct  operation,  in  the  manner  ah'eady 
described  (pp.  307-8).  It  is  better  in  all  such  cases 
to  avoid  the  use  of  arsenic  for  destruction  of  the 
pulp :  it  will  often  be  necessary  to  destroy  it  before 
the  crown  is  removed.  For  a  successful  operation, 
it  is  always  preferable  that  the  root  have  the  pulp 
living.  After  it  is  removed,  the  canal  is  to  be 
enlarged  to  a  suitable  size,  with  the  appropriate 
drill.  If  there  is  any  remaining  sensitiveness  of  the 
dentine,  as  is  very  seldom  the  case,  the  bur  drill  may 
be  used  for  this  purpose ;  but  if  not,  then  the  com- 
mon spear-pointed  drill  will  be  best.  Where,  how- 
ever, the  canal  takes  the  form  of  a  mere  fissure, 
either  the  bur  drill  or  the  four-sided  broach  may  be 
employed.  The  depth  to  which  the  canal  should  be 
enlarged  will  be  determined  by  the  length  of  the 
root,  but  it  should  in  all  cases  be  sufficient  firmly 
to  retain  a  pivot,  w^hich  is  from  one  to  two  lines ; 
and  the  diameter  of  the  hole  w^ill  be  determined  by 
the  size  of  the  root.  The  drills  should  be  frequently 
moistened  with  water,  to  prevent  their  clogging. 
The  shaft  of  the  instrument  in  the  operation  should 
be  in  a  line  with  the  cutting  edges  of  the  two  adjoin- 
ing teeth,  and  midway  between  them,  and  the  drill 
itself  should  follow  the  natural  canal  as  nearly  as 
possible. 


FITTING   THE    CROWN.  363 

FITTING    THE    CROWN. 

The  tooth  selected  should  be  of  a  size,  shape,  and 
color  to  correspond  with  the  natural  crown  which  it 
is  to  represent.  It  should  not  be  ground  on  the 
sides  or  point,  and,  according  to  general  opinion, 
ought  not  to  be  touched  with  the  emery-wheel  at  all. 
A  different  opinion,  however,  is  entertained  by  Dr. 
C.  Palmer.  He  suggests  the  grinding  of  the  entire 
anterior  surface  of  the  artificial  crown,  thus  removing 
the  vitrified  surface  of  the  enamel,  by  which  it  is 
claimed  that  the  appearance  corresponds  much  better 
with  that  of  the  natural  teeth,  which,  in  many  cases, 
at  least,  is  correct.  The  diameter  of  the  neck  of  the 
crown  should  correspond  with  that  of  the  articulating 
surface  of  the  root  to  which  it  is  to  be  attached.  In 
fitting  the  crown  to  the  root,  the  joint  should  be 
made  as  nearly  perfect  as  possible,  for  the  tooth  is 
thus  more  permanent  and  comfortable ;  an  open  joint 
offers  a  receptacle  for  the  lodgment  of  food  and  other 
foreign  substances,  where  they  become  vitiated,  and 
produce  unpleasant  if  not  injurious  effects.  The 
crown  may  be  principally  fitted  to  the  root  without  a 
pivot,  by  dressing  the  latter  with  a  round  or  elliptical 
file,  and  frequently  trying  the  crown  on  in  its  proper 
position.  After  having  been  thus  pretty  accurately 
fitted,  a  trying  pivot  of  soft  wood  should  be  iiitro- 


364  PIVOT    TEETH. 

duced,  by  means  of  which,  grinding  it  to  its  exact 
position,  the  crown  may  be  fitted  to  the  root  in  its 
proper  position. 

For  fitting  pivot  teeth,  Dr.  E.  Townsend  invented 
a  round  file,  with  a  counterpart,  into  which  the  file 
exactly  fits;  with  the  former  of  these  the  root  is 
dressed,  and  with  the  latter  the  articulating  surface 
of  the  crown.  This  apparatus  would  be  good  were  it 
not  for  the  great  difficulty  of  dressing  porcelain  teeth 
with  a  file.  By  care,  a  very  complete  fit  can  be 
made  with  a  round  file  alone.  Some  coloring  mate- 
rial, as  rose  pink,  for  instance,  may  be  put  on  the 
base  of  the  crown,  and  then  the  tooth,  with  the  pivot 
inserted,  set  in  its  place,  when  the  root  will  be 
marked  where  the  crown  has  touched  it,  and  this  can 
be  dressed  at  the  point  of  contact.  This  operation  is 
repeated  till  a  perfect  fit  is  obtained.  This  method 
is  to  be  recommended  to  those  who  have  had  but 
little  experience  in  adjusting  pivot  teeth. 

Another  method  of  making  the  articulation,  is  to 
dress  the  end  of  the  root  square,  and  then  counter- 
sink it  about  half  a  line  deep  with  a  square-ended 
bur,  about  three-fourths  the  diameter  of  the  root. 
The  base  of  the  crown  is  then  ground  down,  by  the 
measure  of  the  bur,  perfectly  round,  so  as  exactly  to 
fit  into  the  depression  in  the  root.  The  bur  used  for 
counter-sinking  the  root  should  have  a  centre-point  to 


ATTACHMENT    OF   THE   CROWN.  365 

fit  into  the  hole  in  the  root,  and  thus  guide  the  instru- 
ment. This  method  of  fitting  on  crowns  is  objection- 
able, by  reason  of  its  too  great  exposure  of  the  root 
of  the  tooth.     Fig.  95  represents  the  bur  used  for 

Fiff.  95. 


this  purpose.     It  is  a  method  now  very  seldom  em- 
ployed. 

Still  another  method  of  making  an  articulation  is, 
to  dress  up  the  root  as  first  described ;  then  take  an 
impression  of  the  part  in  plaster  of  Paris,  and  from 
this  get  a  model  to  which  to  fit  the  crown.  This 
method,  however,  is  advisable  only  in  cases  where  it 
is  desirable  to  avoid  annoyance  to  the  patient  by  a 
tedious  fitting  process. 

ATTACHMENT    OF   THE    CROWN. 

The  means  of  attachment  in  most  common  use  is 
that  of  wood  pivots ;  for  these,  wood  in  the  natural 
condition  is  ordinarily  employed,  though  it  is  much 
improved  by  compression.  The  kind  best  adapted 
for  pivots  is  the  fine-grain,  tough,  slow-growth  hick- 
ory, of  straight,  uniform  fibre,  which  should  be 
thoroughly    seasoned.       For   its    preparation,    take 


366  PIVOT    TEETH. 

blocks,  six  or  eight  inches  long,  and  split  them  into 
rods  about  one  fourth  of  an  inch  square ;  then,  with 
a  knife  and  file,  dress  them  down  to  a  size  one-third 
greater  than  that  of  the  intended  pivots ;  afterward, 
pass  them  through  three  or  four  holes  of  the  ordinary 
drawplate  inverted,  thus  making  them  of  uniform 
thickness  throughout ;  and  finally,  turning  the  draw- 
plate,  pass  them  through  it  in  the  same  manner  as 
wire,  continuing  till  the  rods  are  of  proper  size,  and 
all  the  pores  of  the  wood  are  closed  by  compression. 
They  should  be  slightly  oiled  before  being  drawn 
through  the  plate.  They  may  be  drawn  so  as  just 
to  fit  the  holes  of  the  artificial  crowns,  being,  of 
course,  of  different  sizes.  Pivots  thus  compressed  are 
stiffer,  stronger,  and  far  more  durable  ;  and,  there 
being  greater  density  of  fibre,  there  is  less  absorption 
of  moisture,  less  expansion,  and  less  liability  to 
decay,  than  in  wood  in  the  natural  condition. 

In  arranging  the  crown  in  position,  care  is  neces- 
sary to  prevent  it  from  being  struck  by  the  teeth  of 
the  opposing  jaw, — especially  since  it  often  happens, 
"where  the  natural  crown  has  been  absent  for  some 
time,  that  the  corresponding  tooth  of  the  lower  jaw 
becomes  somewhat  elongated,  and  strikes  forcibly 
against  a  properly-adjusted  pivot  tooth.  Such  a 
difficulty  is  met  either  by  filing  ofi"  the  elongated 
tooth,  or  by  grinding  out  the  palatal  portion  of  the 


ATTACHMENT    OF   THE    CROWN.  367 

artificial  crown  sufficiently  to  accommodate  the  elon- 
gation. The  former  is  the  better  method,  and  should 
always  be  adopted  when  inflammation  of  the  dentine, 
exposure  of  the  pulp,  or  an  irascible  condition  of  the 
surrounding  parts  do  not  forbid  it :  though  in  many 
instances  both  methods  may  be  advantageously  em- 
ployed. But,  by  some  means  the  antagonizing 
teeth  should  always  be  prevented  from  coming  in 
contact  with  the  artificial  crown ;  and  this  latter 
should  never  press  against  the  tooth  on  either  side 
of  it; — indeed,  it  is  better  that  there  be  a  small 
interval  on  each  side. 

When  the  crown  is  in  its  proper  position,  the  hole 
in  the  root  and  that  in  the  crown  do  not  always  have 
precisely  the  same  direction ;  in  which  case,  a  pivot 
will  be  required,  having  a  curvature  according  to  the 
variation ;  and  the  extent  and  direction  of  such  in- 
flection should  be  carefully  observed  while  adjusting 
the  crown  with  the  trying  pivot.  The  pivot  is  to  be 
neatly  and  accurately  fitted  into  the  crown  first,  and 
then  the  length  of  it  required  for  the  root  ascertained 

Fiff.  96. 


with  the  gauge  represented  in  Fig.  90.     This  gauge 
consists  of  a  wire  of  a  size  freely  to  enter  the  pivot- 


368  PIVOT   TEETH. 

hole,  having  a  little  slide  with  a  flange  attached. 
By  introducing  this  wire  into  the  pivot-hole,  the  slide 
is  pressed  back,  and  the  depth  of  the  hole  indicated 
at  once.  The  pivot  is  then  cut  off  accordingly  and 
dressed  to  the  proper  size  and  inclination,  and  gently 
pressed  to  its  place  with  the  thumb  and  fingers. 
Before  being  introduced,  however,  it  may  be  wrapped 
with  gold  foil  which  will  serve  to  protect  the  dentine 
of  the  root  from  decay,  and  also  to  preserve  the  pivot. 
Two  or  three  thicknesses  of  No.  6  gold  foil  may  be 
placed  between  the  crown  and  the  root,  so  as  to  make 
a  more  perfect  joint  and  exclude  the  moisture.  There 
is,  however,  not  much  advantage  in  an  arrangement 
of  this  kind. .  A  thin  sheet  of  Hill's  stopping,  placed 
in  the  joint,  makes  a  better  adaptation  than  the  gold,  » 
and  OS  artificial  may  be  used  for  the  same  purpose, 
and  in  many  instances  is  far  better  than  either  Hill's  , 
stopping  or  gold;  the  canal  in  the  root  above  the 
pivot  should  be  filled  w^ith  gold,  though  in  cases 
where  there  is  a  discharge  through  the  root,  this 
would  not  be  admissible. 

The  canal  at  the  orifice  is  sometimes  considerably 
enlarged  by  decay,  so  that  when  the  crown  is  fitted 
and  the  canal  sufficiently  opened  for  the  reception  of 
the  pivot,  there  will  be  a  cone-shaped  space  which 
the  ordinary  pivot  will  not  fill.  There  are  several 
methods  of  obviating  this  difficulty ;  one  of  these  is, 


ATTACHMENT    OF    THE    CROWN.  369 

completely  to  fill  the  enlargement  with  gold,  and 
then  perforate  this  filling  with  the  proper-sized  drill 
for  the  reception  of  the  pivot ;  or,  which  is  better,  to 
introduce  into  the  canal  a  polished  steel  wire  of  the 
size  of  the  intended  pivot ;  round  this  consolidate  a 
filling  of  gold,  having  first  made  retaining  points  at 
the  proper  places  in  the  dentine ;  finish  perfectly 
flush  with  the  end  of  the  root ;  and  then  withdraw 
the  wire  from  the  canal,  and  it  is  ready  to  receive  the 
pivot  with  the  crown  attached.  Some  operators  form 
the  wood  pivot  of  such  a  shape  as  to  fit  into  and  fill 
the  enlarged  cavity.  Another  method  is,  after  the 
pivot  is  fastened  into  the  crown,  to  build  round  it,  on 
the  base  of  this,  a  portion  of  Hill's  stopping,  of  about 
the  size  and  form  of  the  enlargement  in  the  canal; 
and  then  the  tooth  being  ready  to  insert,  soften  the 
stopping  by  heat,  and  introduce  it  carefully  into 
place.     The  os  artificial  in  such  cases  is  still  better. 

It"  frequently  happens,  in  cases  where  the  pulp 
has  been  dead  for  a  considerable  time,  that  there  is 
more  or  less  discharge  through  the  canal  of  the  root, 
and  a  tooth  is  required  immediately,  or  at  least 
before  there  is  time  for  treatment,  to  abate  the  dis- 
charge. To  such  a  condition  some  arrangement 
must  be  adapted  so  as  not  entirely  to  close  up  the 
canal,  and  preclude  the  escape  of  pus.  For  this  pur- 
pose a  groove  may  be  cut  down  the  wall  of  the  canal, 


370  PIVOT   TEETH. 

or,  perhaps  better,  on  the  side  of  the  pivot  through- 
out its  length,  for  the  discharge  of  the  secretion. 
Where  there  is  irritation  or  liability  to  inflammation, 
a  temporary  pivot  of  soft  wood,  or  of  hard  wood 
loosely  fitted,  should  be  worn ;  for  thus  the  root  is 
less  jarred  by  percussion  on  the  crown,  and,  if  need 
be,  the  crown  and  pivot  can  be  removed. 

METALLIC    PIVOTS. 

The  liability  of  a  pivot  of  wood  to  wear  off'  at  the 
point  between  the  crown  and  the  root,  as  well  as  to 
become  offensive,  and  the  difficulty  of  removing  the 
tooth,  have  led  dentists  to  seek  some  less  objection- 
able material ;  and  metals  have  been  experimented 
upon,  and  found  in  some  respects  preferable.  Gold 
has  been  employed  for  this  purpose  more  than  any 
other  metal.  Pivots  made  of  this  do  not  become 
offensive,  do  not  wear  off',  and  admit  of  any  desired 
curve,  and  of  an  easy  removal  of  the  crown.  There 
are  several  methods  of  attaching  this  kind  of  pivot 
to  a  tooth,  and  a  very  common  one  is,  to  fit  into  the 
hole  in  the  crown  a  piece  of  pivot  wood ;  cut  it  off" 
even  with  the  base  of  the  crown,  and  perforate  it 
with  the  proper-sized  drill  for  the  reception  of  the 
metal  pivot,  which  may  be  roughened  or  barbed  on 
its  sides,  and  then  forced  into  the  place  prepared  for 


METALLIC    PIVOTS.  371 

it.  Another  method  is  to  drill  into  a  block  of  wood ; 
insert  the  pivot,  prepared  as  above,  then  dress  down 
the  wood  round  it  till  this  will  fit  closely  into  the 
crown ;  and  after  it  is  pressed  in,  cut  off  the  pro- 
truding portion  of  wood.  In  either  of  these  methods, 
when  the  wood  becomes  moist,  the  metal  pivot  will 
be  very  firmly  retained.  This  pivot  may  also  be 
attached  to  the  crown  by  soldering.  Place  the  edge 
of  the  tooth  in  plaster  of  Paris ;  set  the  pivot  in  its 
proper  position  in  it ;  fill  this  round  with  fragments 
of  gold  plate,  and  put  on  solder  and  borax ;  heat  up 
with  a  blow-pipe,  and  draw  the  solder  to  the  bottom 
of  the  cavity.  Another  method,  sufficient  for  all 
practical  purposes,  is  to  set  the  pivot  in  place,  and 
pack  round  it  a  stiff  amalgam  of  gold  and  mercury; 
evaporate  the  mercury  by  heat.  A  better  method 
than  any  of  these  is  to  have  teeth  manufactured  with 
a  platinum  tube  inserted,  into  which  the  pivot  can  be 
soldered.  Pilots  may  also  be  attached  to  the  ordi- 
nary plate  teeth. 

For  attaching  the  metal  pivot  to  the  root,  it  is 
sometimes  fitted  tightly  to  the  canal,  and  introduced 
into  it  without  any  other  substance.  This  is  objec- 
tionable on  account  of  the  wearing  of  the  root,  certtun 
to  take  place  if  there  is  the  least  jarring  or  moving 
of  the  crown.  To  obviate  this,  various  methods  have 
been  devised,  one  of  which  is  to  wind  floss  silk  about 


372  PIVOT    TEETH. 

the  pivot  before  introducing  it ;  but  this  soon  becomes 
offensive,  and  requires  frequent  renewal.  Another 
method  is  to  introduce  a  piece  of  wood  into  the  root, 
and  drill  through  it  for  the  reception  of  the  pivot, 
which  is  squared  and  roughened, — squared  to  pre- 
vent it  from  turning  round,  and  roughened  to  secure 
it  from  drawing  out.  But  if  it  is  desirable  to  re- 
move the  tooth  occasionally,  the  pivot  should  not  be 
barbed. 

Metal  tubes  may  be  introduced  into  the  roots  for 
the  reception  of  the  pivots.  These  tubes  are  made  of 
hollow  gold  wire  of  proper  size,  the  method  of  pre- 
paring which  is,  to  take  a  piece  of  No.  30  gold  plate, 
from  four  to  six  inches  long,  and  from  a  third  to  a 
half  inch  wide,  and  bend  it  round  a  piece  of  smooth 
polished  steel  wire  of  the  size  of  the  intended  pivot; 
draw  both  together  through  a  drawplate,  down  to  one 
size  larger  than  the  hole  in  the  root ;  then  take  out 
the  wire,  and  solder  up  the  tube  ;  on  it  cut  a  fine 
thread  with  a  screw-plate ;  from  it  cut  off  from  a  half 
to  three-fourths  of  an  inch  in  length,  and  insert  into 
this  a  piece  of  the  wire  it  was  drawn  upon ;  grasping 
this  section  with  a  small  vice  or  pair  of  nippers,  screw 
it  carefully  into  the  root ;  and  having  introduced  it 
far  enough,  withdraw  the  piece  of  wire,  cut  off  the 
protruding  piece  of  tube  with  a  fine  saw,  and  file  and 
neatly  polish.     The  root  is  thus  ready  for  the  recep- 


I 


METALLIC    PIVOTS.  t         373 

tioti  of  the  crown,  the  pivot  of  which  should  fit  very 
accurately  into  the  tube.  A  very  slight  curvature  of 
the  pivot  will  enable  it  to  retain  a  very  firm  hold  in 
the  tube.  The  tube's  inner  end  may  be  soldered  up 
if  desirable  ;  and  if  there  is  decay  at  the  orifice  of 
the  canal,  a  flange  may  be  soldered  on  to  its  outer 
end,  flush  with  the  end  of  the  root,*  and  the  decayed 
cavity  filled  beneath  it,  the  flange  serving  to  retain 
the  filling  perfectly  in  place.  These  tubes  can  be 
best  fitted  in  with  the  screw,  though  they  are  some- 
times placed  in  without  this,  and  gold  foil  packed 
about  them  to  retain  them.  They  may  be  made  to 
receive  a  square  pivot,  by  being  drawn,  in  their 
manufacture,  on  a  square  wire  instead  of  a  round 
one.  For  the  escape  of  pus,  as  already  referred  to, 
the  pivot  may  be  made  of  hollow  wire,  with  a  hole 
through  the  crown  of  the  tooth. 

A  plate  tooth,  Avith  a  metallic  pivot  attached,  may 
be  used  instead  of  the  ordinary  pivot  tooth ;  and  it 
is  in  some  cases  required,  on  account  of  the  manner 

to 

in  which  the  teeth  antagonize.  But  in  all  cases 
where  a  plate  tooth  is  used,  it  should  have  a  metallic 
base  to  rest  on,  and  cover  the  end  of  the  root.  Pro- 
perly to  construct  this,  an  impression  must  be  ob- 
tained, and  models  and  counter-models  made,  and 
the  base  swaged ;  and  then  to  this  the  pivot  and 
tooth  are  attached.     Irregularity  of  the  teeth,  and 


374  PIVOT    TEETH. 

especially  of  the  root  on  which  the  crown  is  to  rest, 
may  require  a  peculiar  adjustment  of  the  pivot, 
which  may  be  very  happily  effected  by  the  method 
just  referred  to. 

Occasionally,  bad  consequences  follow  the  opera- 
tion of  inserting  a  pivot  tooth,  the  most  frequent  of 
which  is  inflammation  of  the  periosteum.  Rough 
manipulation  is  very  liable  to  induce  this  condition, 
where  there  is  an  inflammatory  diathesis,  in  which 
case  too  great  care  cannot  be  recommended ;  and 
prior  treatment  will  sometimes  be  advantageous. 
After  periostitis  has  supervened,  either  constitutional 
or  local  treatment,  or  both,  may  be  employed, — con- 
stitutional, by  emetics  and  saline  cathartics,  and, 
indeed,  any  agent  that  will  equalize  the  circulation 
and  counteract  the  inflammation ;  and  local,  by  the 
same  means  as  already  prescribed  for  periostitis  else- 
where ;  in  addition  to  which,  it  may  sometimes  be 
necessary  to  remove  the  crown  and  pivot  from  the 
root.  It  is  always  important  to  commence  the  treat- 
ment of  such  cases  at  the  first  indications  of  the 
disease. 

Sometimes,  even  with  considerable  care,  a  crown 
will  be  split  by  the  introduction  or  the  expansion  of 
the  pivot,  in  which  case,  of  course,  another  tooth 
must  be  selected.  When  a  pivot  breaks  off,  and  a 
portion  adheres  in  the  root,  this  may  be  drawn  out 


METALLIC    PIVOTS.  375 

with  pliers,  or  a  pivot-extractor,  or,  if  it  does  not  pro- 
trude enough  for  this,  it  may  be  drilled  out.  A  root 
is  sometimes  split  by  the  expansion  of  a  tightly- 
fitting  pivot,  or  by  a  blow  on  the  crown  of  the  tooth; 
and  when  this  happens,  it  must  be  removed,  since  it 
cannot  be  made  longer  to  retain  a  tooth.  Pivot  teeth 
should  seldom,  if  ever,  be  worn  in  a  mouth  in  which 
teeth  on  plate  are  worn.  They  are  now  far  less  fre- 
quently worn  than  formerly,  because,  perhaps,  of  the 
improved  method  of  inserting  teeth  on  plate.  Under 
favorable  circumstances,  however,  they  may  be  worn 
with  great  comfort  and  usefulness  from  five  to  fifteen 
years. 


CHAPTER  XI. 

EXTRACTION   OF   TEETH. 
GENERAL    REMARKS. 

The  extraction  of  teeth  is  an  important  operation, 
requiring  for  its  proper  performance  skill,  judgment, 
and  experience,  as  well  as  an  accurate  knowledge  of 
the  parts  involved.  Success  in  the  operation  formerly 
was  very  uncertain;  but  now,  from  an  increase  of 
knowledge  in  the  art  of  dental  surgery,  and  from 
great  improvements  in  the  instruments  employed,  the 
operation  is  generally  attended  with  success.  The 
ancients  were  not  strangers  to  this  operation,  as  is 
evidenced  by  relics  found  in  ancient  tombs,  with 
teeth  absent,  under  such  circumstances  as  to  warrant 
the  conclusion  that  they  were  removed  by  the  sur- 
geon. Extracting  instruments  of  very  ancient  date 
have  also  been  found;  and  ancient  writers,  too,  refer 
to  the  operation  as  one  not  much  more  pleasant  then 
than  now.  The  demand  for  this  operation  rises  not 
from  fancy,  fashion,  or  caprice,  but  from  dire  neces- 
sity— a  necessity,  too,  of  great  frequency.  Very  few 
individuals  in  this   country  arrive  at  a  mature  age 


EXTRACTION    OF   TEETH.  377 

without  being  required  to  submit  to  it;  and,  in- 
deed, the  majority,  before  middle  age,  lose  in  this 
manner  from  four  to  ten  teeth,  and  many,  all.  The 
following  are  j-ome  of  the  objects  for  which  a  resort 
is  had  to  this  operation  : — 

1.  To  obtain  relief  from  pain,  caused  either  by 
disease  of  the  pulp,  by  inflammation  of  the  perios- 
teum, or  by  any  other  affection  involving  the  teeth, 
that  cannot  be  readily  controlled  without  their 
removal. 

2.  To  prevent  pain  in  future.  This,  of  course,  has 
reference  only  to  those  teeth  which  are  very  much 
decayed,  or  rendered  useless  bj^  any  cause,  and  which 
are  liable  at  any  time  to  occasion  disease  in  the  parts 
about  them. 

3.  To  save  sound  teeth  from  the  attack  and  ravage 
of  decay.  This  implies  those  teeth  which,  by  their 
offensive  condition,  would  prove  injurious  to  healthy 
teeth. 

4.  To  relieve  a  diseased  condition  of  the  contigu- 
ous parts,  such  as  alveolar  abscess,  neuralgia  excited 
by  dental  irritation,  diseased  antrum — and  sometimes, 
indeed,  remote  parts,  which  are  in  many  instances 
affected  by  diseased  teeth. 

5.  To  anticipate  and  obviate  irregularity.  Of  this 
there  are  many  cases,  in  which  all  the  teeth  cannot 
be  accommodated  with  a  proper  position  in  the  arch, 


378  EXTRACTION    OF    TEETH. 

and  in  which  the  removal  of  one  or  more  of  them  for 
this  purj^ose  becomes  a  necessity,  if  regularity  and 
symmetry  are  to  be  secured. 

6.  To  prepare  the  mouth  for  a  proper  reception  of 
artificial  teeth  on  plates ;  though  plates  are  some- 
times inserted,  with  the  roots  of  the  teeth  remaining, 
which  is  admissible  only  when  the  roots  and  the  parts 
about  them  are  healthy ;  otherwise  they  should  be 
removed. 

Before  anything  else  is  done,  every  case  presented 
should  be  carefully  examined,  in  order  to  ascertain 
all  the  circumstances  and  conditions  that  might  in 
any  way  affect  the  operation.  It  is  important  to 
arrive  at  a  correct  conclusion  in  regard  to  the  tooth 
or  teeth  to  be  removed ;  the  number  of  roots,  their 
inclination,  and  the  character  of  their  attachment ; 
in  what  manner,  and  to  what  extent,  the  surrounding 
parts  will  be  affected  by  their  removal;  and  the 
probable  amount  of  force  necessary  for  this  purpose. 
The  operator  will  in  many  instances  be  referred  to 
the  wrong  tooth ;  for  a  sound  and  healthy  one  is 
sometimes  painful  from  sympathy,  and  standing  in 
contact  with  a  decayed  and  painful  tooth,  makes  it 
frequently  difficult  for  the  patient  to  determine  in 
which  the  pain  exists  ;  and  sometimes  difficult  for  the 
operator,  too,  especially  where  the  decay  is  on  a 
proximal   portion    of    the    tooth,    and    not    easy    of 


GENERAL    REMARKS.  379 

approach.  In  all  such  cases,  great  care  should  be 
exercised,  and  a  thorough  examination  made.  There 
is  often  extensive  decay  on  the  proximal  portion  of 
the  tooth,  that  is  not  apparent  at  first  view. 

The  constitution  is  also  to  be  noted — its  peculiar- 
ities, tendencies,  and  susceptibilities ;  as  these  will 
often  modify  the  operation.  A  highly  nervous  tem- 
perament will  not  endure  an  operation  that  one  of 
a  different  character  will  undergo  with  impunity. 
There  may  also  be  idiosyncrasies  and  conditions  that 
will  forbid  the  extraction  of  a  tooth.  One  of  these, 
and  not  the  least  formidable,  is  a  hemorrhagic  dia- 
thesis. 

The  manner  of  performing  the  operation  is  an  im- 
portant consideration  :  it  should  not  be  precipitate  or 
hurried.  A  very  good  criterion  is,  that  the  eye 
should  critically  follow,  and  the  mind  attentively 
comprehend,  every  movement  of  the  hand  and  instru- 
ment. It  is  a  very  common  method  to  seize  the 
tooth,  turn  away  or  shut  the  eyes,  and  make  the  most 
rapid  motions  possible,  regardless  of  consequences. 
Accidents,  such  as  breaking  the  tooth,  fracturing  the 
alveolus,  laceration  of  the  soft  parts,  and  rupture  of 
the  blood-vessels,  are  very  liable  to  follow  a  hurried 
execution;  and  there  are  many  cases  on  record  in 
which  injury  has  resulted  from  a  rapid  application  of 
force  in  the  extraction  of  teeth.     The  ancients  were 


380  EXTRACTION    OF   TEETH. 

cautious  in  this  particular :  it  is  recorded  of  them 
that  they  made  extracting  instruments  of  lead,  to 
prevent  injury  from  the  employment  of  too  great 
force.  It  is  difficult,  indeed,  always  to  determine 
what  amount  of  force  may  be  necessary  for  the 
removal  of  a  tooth  in  any  given  case ;  though  by  long 
and  close  observation,  it  may  be  pretty  accurately 
calculated ;  and  it  is  important  for  the  operator  to 
know  it,  so  as  to  prepare  for  the  emergency,  and  to 
select  the  instrument  appropriate  to  the  occasion. 
In  order  to  be  successful,  an  operator  must  be  confi- 
dent of  his  ability,  and  to  be  so,  he  must  be  possessed 
of  it.  Pie  should  be  familiar  with  the  anatomical 
structure  of  the  parts  to  be  operated  upon ;  should 
understand  the  physiological  and  pathological  con- 
ditions of  the  parts  adjacent;  and  should  properly 
appreciate  their  influence  on,  and  their  connection 
with,  the  teeth. 

There  is  a  great  difference  in  teeth  with  regard  to 
their  facility  of  removal.  Those  most  difficult  to 
extract  possess  the  following  peculiarities  :  shortness 
and  thickness  of  crown ;  in  the  incisors,  thickness — 
the  edges  of  the  superior  and  the  inferior  meeting 
squarely  on,  or  deviating  but  little  from  their  points ; 
freedom  from  prominences  on  the  crowns  of  the  mo- 
lars and  bicuspids,  their  masticating  surfaces  being 
smooth ;  regularity  in  arrangement,  all  being  in  cor- 


GENERAL    REMARKS.  381 

rect  position  and  in  contact  with  one  another-;  color 
slightly  yellow  ;  denseness  and  thickness  of  alveolus  ; 
unyielding  firmness  of  the  soft  tissues  ;  lack  of  promi- 
nences on  the  gums  to  indicate  the  size  and  position 
of  the  roots.  Another  class  of  teeth,  differing  in 
characteristics  from  those  of  the  above,  are  also  very 
difficult  of  extraction,  namely  :  those  having  crowns 
of  medium  length  and  of  a  diameter  at  the  neck  much 
less  than  at  the  masticating  surface ;  roots  long  and 
divergent,  and  in  some  cases  considerably  curved ; 
and  often  a  very  firm  union  with  the  alveolus,  so  that 
a  portion  remains  adhering  to  the  tooth  when  it  is 
extracted,  which  occurs  more  frequently  with  the 
superior  cuspid  teeth  than  with  any  others  ;  and  often 
the  septum  betwen  the  roots  is  so  firmly  embraced 
by  them,  especially  when  they  converge,  that  it  is 
brought  awny  with  the  tooth  on  its  extraction.  Bony 
union  of  the  teeth  has  been  enumerated  as  one  of  the 
occasional  obstacles  in  extraction  of  the  teeth ;  but 
this  rarely  if  ever  occurs — the  mode  of  development 
almost  precluding  the  possibility  of  its  existence — so 
that  it  need  scarcely  be  reckoned.  Exostosis  of  the 
root  sometimes  renders  extraction  very  difficult, 
especially  when  the  enlargement  attaches  to  the  point 
of  the  root,  and  forms  a  bulb  larger  than  the  diameter 
of  the  root  elsewhere.  It  is  then  like  a  ball  in  a 
socket,  and  if  the  walls  of  the  alveolus  are  thick  and 


382  EXTRACTION    OF    TEETH. 

firm,  and  closely  embrace  the  root,  the  tooth  is  very 
securely  retained.  Exostosis  of  the  same  extent  in 
the  inferior  as  in  the  exterior  teeth  will  render  the 
latter  the  more  difficult  to  remove,  because  of  the 
greater  density  of  the  inferior  maxilhi ;  and  it  has 
been  maintained  that  this  cause  would  produce  a 
like  difference  even  in  the  normal  condition  of  the 
organs;  but  experience  does  not  warrant  the  opinion. 
The  superior  molars  have  more  numerous  and  more 
divergent  roots  than  the  inferior ;  and  the  roots  of 
the  anterior  superior  teeth  are  much  larger,  and 
consequently  have  a  greater  amount  of  attachment, 
than  the  anterior  inferior  ones.  In  a  healthy  condi- 
tion, the  periosteum  of  the  root  has  comparatively 
little  sensibility ;  but  in  proportion  as  it  is  sub- 
jected to  acute  disease,  is  the  sensibility,  and  thus 
the  pain  consequent  on  the  removal  of  the  tooth, 
augmented. 

Instruments  adapted  to  all  the  different  forms  and 
locations  of  the  teeth  are  requisite  in  the  various 
operations  of  extraction.  It  is  impossible  to  remove 
all  teeth  in  a  proper  manner  with  but  three  or  four 
instruments,  as  recommended  by  some. 

For  any  kind  of  successful  manipulation  in  the 
mouth,  and  especially  that  involved  in  the  extraction 
of  teeth,  the  patient  should  be  placed  in  such  a  posi- 
tion as  to  make  him  the  most  comfortable,  and  to 


INDICATIONS    FOR    EXTRACTION.  383 

secure  to  the  operator  the  greatest  facility  of  execu- 
tion. But  (lifFerent  positions,  of  course,  will  be  re- 
quired for  the  removal  of  different  teeth.  Finally, 
there  should  be  as  little  show  of  preparation,  and  as 
little  display  of  instruments,  as  possible, — thus  to 
avoid  exciting  the  nervous  apprehensions  of  the 
patient ;  and  the  operator  should  at  all  times  exhibit 
a  gentle  and  encouraging  deportment,  yet  work 
promptly  and  surely. 


INDICATIONS    FOR    EXTRACTION. 

The  most  common  and  imperative  indication  is, 
continued  and  violent  toothache.  In  all  cases  where 
the  teeth  are  diseased  and  painful,  and  cannot  be 
restored  to  health,  they  should  be  removed.  There 
are,  however,  few  cases  of  diseased  teeth  that  cannot 
be  relieved  by  the  present  methods  of  treatment,  so 
as  to  remain  in  the  mouth  with  some  degree  of  com- 
fort and  usefulness.  Alveolar  abscess,  terminating 
on  the  outside  of  the  face,  or  tending  to  it,  always 
indicates  the  removal  of  the  offending  tooth.  Chronic 
inflammation  of  the  investing  membrane  used  to  be 
considered  an  indication  for  extraction ;  but  it  is 
found  that  many  cases  thus  affected  may  by  judi- 
cious treatment  be  restored  to  comparative  health. 
Ulceration  of  the  investing  membrane  clearly  points 


384  EXTRACTION    OF    TEETH. 

to  extraction  as  the  remedy.  Teeth  that  have  no 
antagonists,  and  that,  on  this  account,  keep  up  an 
irritable  condition  in  the  contiguous  parts,  should 
be  removed ;  and  so,  as  a  general  rule,  should  super- 
numerary teeth.  In  order  to  relieve  a  crowded 
condition  of  the  teeth,  it  is  sometimes  necessary  to 
remove  one  or  more,  even  though  they  may  be 
healthy. 

Till  within  the  last  few  years,  the  existence  of  an 
alveolar  abscess  was  considered  an  indication  for  the 
removal  of  the  tooth  from  which  it  proceeded,  but 
under  the  present  mode  of  treatment,  except  in  very 
aggravated  cases,  a  simple  abscess  is  not  reckoned  a 
sufficient  cause  for  extraction. 

The  posterior  teeth  may  be  removed  for  causes 
that  would  not  warrant  the  removal  of  the  anterior. 
All  dead  teeth  and  roots  that  produce  or  keep  up 
irritation  should  be  removed,  especially  if  the  ten- 
dency is  persistent. 

The  temporary  teeth  that  are  not  cast  at  or  near 
the  time  their  respective  permanent  teeth  should 
appear  through  the  gum,  ought  to  be  removed ;  but 
caution  must  always  be  exercised,  lest  they  be  re- 
moved too  soon.  Painful  and  uncontrollable  disease 
may  indicate  their  removal  long  before  the  period 
just  mentioned ;  yet  they  should  not  be  removed  on 
account  of  diseased  condition  unless  the  rudiments  of 


EXTRACTING   INSTRUMENTS.  385 

the  permanent  teeth  are  likely  to  suffer  thereby. 
A  crowded  condition  of  the  permanent  with  the  tem- 
porary teeth  may  indicate  the  removal  of  one  or  more 
of  the  latter.  It  is  important  to  understand  the  true 
indications  for  the  removal  of  temporary  teeth ;  in 
these,  as  in  the  permanent  teeth,  apparent  indications 
are  liable  to  be  mistaken  for  real  ones.  Teeth  may 
sometimes,  even  though  undecayed,  produce  nervous 
affections,  and  in  such  a  manner  as  to  render  their 
removal  necessary.  This  indication  is  most  frequent 
with  teeth  affected  by  exostosis. 

A  high  state  of  inflammation  in  the  contiguous 
parts  is  regarded  by  some  as  a  counter  indication ; 
but  it  can  be  such  only  in  cases  in  which  the  inflam- 
mation would  be  increased  by  the  operation ;  and  this 
would  happen  only  where  there  is  a  decided  inflam- 
matory diathesis,  which  peculiarity  can  be  readily 
detected  by  careful  observation. 


EXTRACTING   INSTRUMENTS. 

Numerous  and  various  instruments  have  been  em- 
ployed for  extracting  teeth ;  and  each  of  these  has 
passed  through  various  modifications.  Imperfection 
and  want  of  adaptation  have,  till  within  a  few  years, 
characterized  them  all  in  a  marked  degree,  as  indi- 
cated by  the  numerous  changes  they  have  undergone. 


386  EXTRACTION    OF   TEETH. 

Two  general  classes  comprehend  them  all,  repre- 
sented by  the  key  and  the  forceps.  The  former 
makes  its  attachment  on  one  side  of  the  tooth,  com- 
ing in  contact  with  but  a  small  portion  of  it,  and  has 
a  resting  point  for  a  fulcrum  on  the  adjacent  parts, 
the  gum  and  the  alveolus.  The  latter  embraces  the 
tooth  on  both  sides,  and  has  no  fulcrum  resting  on 
the  adjacent  parts.  There  are  other  instruments 
somewhat  different  from  these  in  their  application ; 
but  the  principle  on  which  they  operate  is  the  same. 
For  instance,  the  elevator  has  a  point  of  embrace  or 
contact  with  the  teeth,  and  a  fulcrum  or  resting  point 
on  the  adjacent  parts,  the  power  being  applied  to  the 
handle,  as  to  a  lever.  The  screw  makes  its  attach- 
ment inside  of  the  tooth,  instead  of  outside,  like  the 
forceps,  and  does  not  touch  any  other  part. 

There  should  always  be  at  hand  a  sufficient  num- 
ber and  variety  of  instruments  to  meet  every  case, 
however  rare  its  occurrence.  Desirabode  recom- 
mends the  employment  of  but  four  instruments  for 
the  removal  of  all  the  teeth.  The  first  is  a  forceps, 
and  the  other  three  are  nothing  more  than  so  many 
different  forms  of  the  elevator.  He  was  not  fjimiliar 
with  the  present  improvements  in  extracting  instru- 
ments, or  he  could  not  have  made  such  a  recom- 
mendation. 


THE    KEY.  387 


THE    KEY. 


The  principle  of  this  instrument  was  at  a  very 
early  period  brought  into  requisition  for  the  extrac- 
tion of  teeth ;  it  is  emphatically  an  old  instrument. 
It  consists  of  a  shaft  six  inches  long,  with  a  handle 
four  inches,  attached  at  right  angles,  while  the  hook 
is  attached  laterally  at  the  other  end  of  the  shaft, 
and  the  bolster,  either  movable  or  fixed,  to  the  side 
of  it,  immediately  below  the  articulation  of  the  hook. 
This  instrument  has  passed  through  a  great  variety 
of  forms  and  modifications  ;  having  the  shaft  straight, 
curved,  or  double  curved ;  the  fulcrum  large,  small, 
flat,  round,  long,  short,  fixed,  movable,  and  anterior, 
posterior,  or  opposite  to  the  point  of  the  hook.  There 
has  also  been  a  great  variety  of  forms  of  the  hook  ; 
and  it  has  been  made  with  machinery  attached,  to 
control  its  grasp,  the  object  of  which  is  to  prevent 
the  instrument  from  slipping  off  the  tooth,  and  skill 
in  the  use  of  which  would  doubtless  add  to  the  effi- 
ciency of  the  instrument.  The  principle  of  the  for- 
ceps, too,  has  been  combined  with  the  key,  and  pro- 
bably with  very  decided  advantage. 

The  modus  operandi  of  the  key  is  worthy  of  some 
consideration.  The  hook  is  attached  to  the  shaft 
directly  above  the  bolster,  and  starts  off  at  a  right 
angle  with  its  vertical  axis,  but  curves  down  to  the 


388  EXTRACTION    OF   TEETH. 

point,  almost  or  quite  as  low  as  the  base  of  the  bolster. 
When  properly  constructed,  the  hook  embraces  the 
tooth  at  the  neck  on  one  side,  and  the  bolster  rests  a 
little  below  this  on  the  other.  When  the  instrument 
is  applied  to  a  tooth,  the  centre  of  the  shaft  is  the 
axis  of  motion ;  but  as  force  is  applied  to  the  instru- 
ment, this  axis  is  transferred  from  the  shaft  to  the 
base  of  the  bolster,  which  is  the  centre  of  motion  the 
moment  it  is  fixed  on  the  gums  and  alveolus,  and  the 
shaft  describes  an  arc  about  it.  Now,  as  a  result 
of  this  motion  and  arrangement,  the  line  of  force  is  at 
an  angle  of  from  forty  to  sixty  degrees  with  the  axis 
of  the  tooth ;  and  hence  it  is  at  this  angle  that  the 
tooth  must  be  extracted,  if  at  all.  The  axis  of  power 
exerted  on  the  tooth  by  the  instrument  is  in  a  line 
from  the  point  of  the  hook  to  its  attachment  to  the 
shaft ;  and  the  line  of  this  force  has  its  termination 
below  the  neck  of  the  tooth  on  one  side,  and  just 
above  the  crown  on  the  opposite  side.  The  angle 
formed  by  the  line  of  power  with  the  axis  of  the 
tooth  is  different  in  the  different  relative  positions  of 
the  key  to  the  tooth.  If  the  instrument  is  applied  to 
an  inferior  molar,  with  the  bolster  on  the  inside,  the 
angle  of  the  line  of  force  with  the  axis  of  the  tooth  is 
about  forty  degrees ;  but  if  placed  on  the  outside  of 
the  jaw,  as  recommended  by  some,  the  angle  con- 
tained by  the  line  of  power  and  the  axis  of  the  tooth 


THE    KEY.  389 

is  sixty  degrees  or  more.  The  line  of  force  is  not 
changed  by  any  form  the  hook  may  assume  ; — it  may 
be  regularly  or  irregularly  curved,  or  be  turned  at 
right  angles,  and  yet  the  line  of  force  is  not  changed. 
Indeed,  this  line  cannot  be  changed  except  by 
changing  the  relative  position  of  the  hook  and  its  at- 
tachment. This  application  of  the  power  constitutes 
one  of  the  prominent  objections  to  the  use  of  the  in- 
strument ;  the  force  is  applied  at  too  great  an  angle 
with  the  axis  of  the  tooth,  and  hence,  in  numerous 
instances  it  is  broken  off.  The  bolster  of  the  key 
rests,  in  the  operation,  on  the  gum,  on  which  it 
exerts  great  pressure,  and  which  it  always  bruises, 
and  frequently  lacerates  in  a  cruel  manner;  the  press- 
ure exerted  by  the  bolsters  of  the  variously  con- 
structed keys  differs  but  little ;  though,  perhaps,  the 
bolster  which  has  a  broad  base,  and  is  attached  to  the 
shaft  by  a  joint,  would  cause  less  pain  to  the  patient 
by  its  pressure,  and  be  much  less  liable  to  lacerate, 
or  cut  the  gum,  than  the  small  and  permanent  one. 
The  pressure  of  the  bolster  on  the  gum  and  process 
is  always  greater  than  the  power  required  to  extract 
a  tooth;  and  this  extreme  pressure  and  its  conse- 
quences constitute  another  strong  objection  to  the 
use  of  the  key.  The  power  being  applied  at  a  disad- 
vantage, much  more  is  required  than  when  economi- 
cally applied. 


390  EXTRACTION    OF   TEETH. 

This  instrument  is  so  seldom  employed  for  the 
extraction  of  teeth,  that  any  very  special  directions 
as  to  its  use  will  scarcely  be  required ;  yet  a  few  gen- 
eral suggestions  may  not  be  out  of  place.  Whether 
a  tooth  should  be  drawn  inward  or  outward  depends 
on  its  position  and  inclination.  As  a  general  rule  for 
the  removal  of  the  molars,  the  bolster  should  be 
placed  on  the  inside  of  the  inferior  teeth  and  on  the 
outside  of  the  superior.  For  removing  the  lower 
teeth  of  the  left  side,  the  operator  should  stand  at  the 
right  of  the  patient ;  and  for  the  teeth  of  the  right 
side,  in  front  or  at  the  right.  For  the  inferior  teeth 
of  the  right  side,  he  should  stand  at  the  right  of  the 
patient;  and  for  the  left  superior,  in  front  of  him. 
There  have  been  a  great  many  different  opinions  as 
to  the  manner  of  applying  and  using  this  instrument. 
One  recommends  that  "  the  teeth  should  be  always 
turned  towards  the  tongue."  Another,  "that  the 
fulcrum  should  be  so  placed  that  it  would  not  come 
in  contact  with  the  tooth."  Another  directs  :  "  Place 
the  fulcrum  on  the  margin  of  the  gum."  Another : 
"Place  the  fulcrum  on  the  gum  below  its  margin." 
Another  suggests,  "  that  the  fulcrum  be  placed  on  the 
side  of  the  tooth  opposite  the  point  of  the  hook." 
Again,  we  are  directed  that  the  tooth  should  be  drawn 
from  the  higher  alveolus."  This  great  diversity  of 
opinion  as  to  the  manner  of  using  the  key,  as  well  as 


FORCEPS.  391 

the  great  variety  of  changes  in  its  form,  is  evidence 
that  it  is,  at  best,  a  very  imperfect  instrument.  It  is 
impossible  to  embrace  a  tooth  as  deep  with  it  as  with 
well-constructed  forceps ;  and  with  it,  the  liability  to 
accident  in  the  extraction  of  teeth  is  much  greater 
than  with  any  other  instrument.  A  strong  advocate 
of  this  instrument  says  that  the  key  always  produces 
injury;  but  the  greatest  skill  exhibits  the  least 
injury." 

FORCEPS. 

The  forceps  are  the  most  efficient  extracting  instru- 
ments in  use,  and  the  improvements  made  in  them 
during  the  last  few  years  have  been  very  great; 
indeed,  twenty  years  ago  they  were  not  made  with 
any  special  adaptation  whatever,  and  were  totally 
unfit  to  be  used  for  the  extraction  of  teeth ;  but  now 
they  are  constructed  with  such  various  shapes  and 
curves,  as  to  facilitate  their  approach  to  the  teeth, 
whatever  their  position  in  the  mouth  may  be,  and  to 
fit  all  the  various  forms,  and  make  the  most  perfect 
embrace  of  the  teeth  possible.  Forceps,  with  the  pre- 
sent improvements,  take  a  deeper  and  more  thorough 
hold  on  the  teeth  than  any  other  instrument.  The 
beaks  may  be  made  so  thin  that  they  will  penetrate 
between  the  roots  and  alveolus,  and  the  adaptation  so 


392  EXTRACTION    OF    TEETH. 

complete  that  the  instrument  will  not  slip  or  move 
from  its  position  when  placed.  The  form  of  the  beaks 
should  be  such  as  to  fit  the  crown  without  pressing  on 
it,  and  yet  perfectly  embrace  the  neck  of  the  tooth ; 
and  the  entire  instrument  of  such  form  and  curve  as 
to  give  to  the  hand,  arm,  and  body  of  the  operator  the 
best  position  for  ease  and  facility  of  execution. 

There  are  various  opinions  as  to  the  position,  rela- 
tive to  the  patient,  which  the  operator  should  occupy 
while  extracting  teeth  with  the  forceps.  Some 
recommend  different  positions  for  the  removal  of 
different  teeth ;  but  it  is  preferable,  on  many  accounts, 
to  occupy  as  nearly  as  possible  the  same  position  in 
the  removal  of  all;  and  this  is  to  the  right  and  a 
little  back  of  the  patient. 

The  forceps  for  removing  the  superior  incisors  are 
straight,  and  have  thin  beaks,  which  are  sufficiently 
broad  to  embrace  the  anterior  and  the  posterior  sur- 
faces of  the  teeth  entire  (Fig.  97) ;  and  they  should 

Fi-.  97. 


be  much  broader  for  the  centrals  than  for  the  laterals. 
The  points  should  not  be  so  broad,  however,  as  to 


FORCEPS. 


393 


come  in  contact  with  the  contiguous  teeth  in  the 
rotary  motion  made  to  break  up  the  attachment. 
The  same  principle  in  regard  to  the  Avidth  of  the  for- 
ceps is  to  be  observed  for  the  lateral  incisors  and 
cuspids.  The  ordinary  straight  root  forceps  may  be 
employed  for  the  extraction  of  the  lateral  incisors ; 
though,  for  this  purpose,  it  is  desirable  that  their 
beaks  be  somewhat  thinner  than  usual.  For  the 
superior  cuspid  teeth,  the  ordinary  bicuspid  forceps 
are  frequently  used,  but  their  beaks  are  commonly 
too  narrow,  and  those  of  the  central  incisor  forceps 
too  thin.  The  cuspid  forceps  should  be  about  as 
wide  as  those  for  the  central  incisors,  with  the  thick- 
ness of  the  bicuspid  forceps  (Fig.  9S),  and  with  a 

Fiff.  98. 


greater  concavity,  so  as  to  fit  the  neck  of  the  tooth. 
The  superior  bicuspid  forceps  have  narrow,  thick,  and 
quite  concave  beaks,  and  the  instrument  is  straight, 
or  nearly  so;  though  for  the  second  bicuspids, 
especially  in  a  small  mouth,  it  should  have  some 
anterior  curvature.  (Fig.  99.)  One  pair  of  forceps 
will  serve  for  both  sides,  though  it  is  desirable  to 


394 


EXTRACTION    OF    TEETH. 


have  one  for    the  fist  and    another   for  the    second 
bicuspid.     For  the  removal  of  the  bicuspids,  there  is 

Fig.  99. 


a  form  of  forceps  with  thick,  smooth  beaks,  and  of 
such  a  form  as,  by  pressure,  to  force  the  tooth  from 
its  socket,  taking  advantage  for  this  purpose  of  the 
conical  form  of  the  root.  The  superior  molar  for- 
ceps, a  pair  for  each  side,  have  one  of  the  beaks  a 
single  concave,  to  embrace  the  palatine  root,  and  the 
other  a  double  concave,  with  a  projecting  point  from 
the  centre  of  the  beak,  to  pass  into  the  bifurcation, 
and  with  the  edge  of  the  beak  so  formed  as  to  em- 
brace the  two  palatine  roots.  The  concavity  and  cur- 
vature of  the  beaks  should  be  just  sufficient  to  accom- 
modate the  crown  of  the  tooth.  These  forceps  should 
have  a  double  curve,  to  facilitate  their  approach  to 
the  teeth — an  anterior  curve  just  above  the  joint  and 
a  downward  curve  just  below  it ;  sometimes,  also, 
a  lateral  curve  above  the  joint,  throwing  the  instru- 
ment more  toward  the  angle  of  the  mouth.  (Fig- 
100.) 

For  the  second  molars,  the  forceps  should  have  a 
little  more  curve  above  the  joint  than  for  the  first. 


I 


I 


t 


FORCEPS. 


395 


A  third  pair  of  forceps  for  these  teeth,  and  especially 
for  the   roots  before  they  are  separated,  have  the 


Fig.  100. 


inner  beak  similar  to  the  one  above,  and  the  outer  a 
curved,  attenuated,  sharp  point,  to  pass  between  the 


FLf.  101. 


buccal  roots  (Fig.  101).    The  forceps  for  the  superior 
dens  sapientice  have  two  single-concave  beaks,  made 


396 


EXTRACTION    OF   TEETH. 


to  embrace  the  tooth,  as  though  it  were  cylindrical, 
or  nearly  so,  at  its  neck.  The  instrument  has  two 
curves,  or  rather  angles,  the  one  forward  and  the 
other  downward,  so  that  its  handle  is  somewhat 
anterior  to,  but  almost  parallel  with,  the  axis  of  the 
tooth.      (Fig-  102.)     It  is  a  principle  that  should  be 

Fig.  102. 


observed  in  all  forceps,  that  the  handle  of  the  instru- 
ment when  placed  upon  the  tooth  be  as  nearly  par- 
allel with  the  axis  of  the  latter  as  possible,  and  as 


Fig.  103 


nearly  in  a  line  with  it  as  the  location  of  the  tooth, 
the  size  of  the  mouth,  and  other  circumstances  will 
admit. 

The   forceps  for   the   inferior  incisors    may  have 
either  a  lateral  or  a  transverse  curve, — ^almost  to  a 


FORCEPS. 


397 


right  angle  if  transverse,  but  if  lateral,  not  more 
than  half  that  inclination,  (Fig.  103.)  The  ordi- 
nary, slighth^  curved  root  forceps  may  be  used  for 
the    extraction    of  these   teeth.     (Fig.  104.)      The 

¥hr.    104. 


beaks  should  be  very  narrow  and  thin,  for  a  great 
amount  of  force  is  not  required  for  the  extraction  of 
these  teeth.     The  beaks  of  the  inferior  incisor  for- 

Fig.  105. 


ceps  should  be  relatively  broader  than  those  of  the 
forceps  for  the  superior  incisors.  Rotary  motion  in 
the  extraction  of  inferior  incisors  is  not  admissible 
unless  the  roots  be  cylindrical,  or  nearly  so.  The  in- 
ferior bicuspid  forceps  are  well  adapted  to  the  re- 


398 


EXTRACTION    OF   TEETH. 


moval  of  the  inferior  cuspids  also.  These  forceps,  two 
in  number,  one  for  each  side,  are  of  different  forms. 
(Fig.  105.)  The  beaks  are  narrow,  thick,  and  quite 
concave.  The  instrument  for  the  right  side  has  a 
lateral  curvature,  ^vhich  brings  the  handle  out  at  the 
angle  of  the  mouth,  and  is  necessary  in  order  to  ob- 
viate a  contact  with  the  superior  teeth.  The  forceps 
for  the  left  side  have  beaks  of  the  same  form.  They 
are  bent  to  almost  a  right  angle  above  the  joint, 
while  below  it  the  handle  is  thrown  upward;  and  their 
inner  beak  is  longer  than  the  outer.  The  inferior 
molar  forceps  (Fig.  106)  are  two  in  number,  that  for 


the  right  side  being  curved  outward  and  forward,  and 
that  for  the  left  forward  and  upward,  the  beak  mak- 
ing almost  a  right  angle  with  the  body  of  the  instru- 


FORCEPS.  399 

ment,  and  the  inner  beak  of  each  being  longer  than 
the  outer.  The  beak  should  be  of  sufficient  breadth 
to  embrace  the  entire  side  of  the  tooth,  of  double- 
concave  form,  with  a  ridge  and  a  long  point  in  the 
centre  of  the  beak,  to  pass  into  the  bifurcation  of  the 
roots.  The  inner  beak  of  these  forceps  should  be 
longer  than  the  outer,  for  the  teeth  on  which  they 
are  designed  to  operate  have  an  inward  inclination, 
and  the  outer  alveolus  is  higher  than  the  inner. 

A  pair  of  forceps  for  the  left  side,  similar  in  form 
to  those  for  the  right,  would  be  preferable  to  the 
ordinary  left  forceps,  when  the  mouth  can  be  opened 
wide ;  and  the  curvature  of  the  handle  of  this  instru- 


ment would  be  toward  the  centre  of  the  mouth,  in- 
stead of  outward,  as  that  of  the  right  forceps.  With 
this  form  of  forceps  more  power  can  be  exerted  than 
with  the  ordinary  left  inferior  forceps. 

A  forceps  similar  in  general  form  to  that  for  the 
extraction  of  the  inferior  molars  of  the  right  side  has 
been  devised  by  Dr.  J.  A.  Watling,  for  the  removal 
of  the  lower  molars  of  the  left  side. 

The  instrument  has  a  little  more  upward  and  for- 
ward curve  above  the  joint  than  for  the  right  side,  to 


400 


EXTRACTION    OF   TEETH. 


facilitate  its  approach  to  and  action  upon  the  tooth  for 
which  it  is  designed ;  it  is  a  little  longer  than  that  for 
the  right  side.  This  instrument  is  much  more  easily 
controlled  than  the  ordinary  forceps  used  for  extract- 
ing these  teeth,  and  with  it  more  force  can  be  ap- 
plied. It  is  far  preferable  to  any  forceps  hitherto 
used  for  the  extraction  of  the  left  inferior  molars.  It 
is  represented  by  Fig.  108. 


Fiff.  lOS. 


Forceps  for  the  removal  of  the  inferior  dens  sapi- 
entice  have  large  single-concave  beaks,  to  make  a 
general  embrace  of  the  tooth,  and  have  but  one 
curve,  which  is  between  the  joint  and  the  point,  and 
is  almost  a  right  angle.  (Fig.  109.)  One  pair  of 
forceps  of  this  kind  is  quite  sufficient  for  both  the 
right  and  the  left  side.  The  forceps  denominated 
Physics  forceps  are  also  sometimes  employed  for  the 
removal  of  the  wisdom-teeth.  These  are  constructed 
with  thick,  sharp  blades,  the  edges  of  which  come 
squarely  together,  and  the  points  sometimes  have  an 
enlargement  on  them.      They  are  curved  almost  to  a 


FORCEPS. 


401 


right  angle,  to  facilitate  their  adaptation.   (Fig.  109.) 
There  are  two  or  three  different  forms  of  Physic's 

forceps. 

Fiir.  109. 


Of  the  variety  of  root  forceps  now  used,  those  for 
the  removal  of  the  anterior  teeth  are  straight,  or  but 
slightly  curved,  with  long,  thin,  sharp-edged  beaks, 
and  of  a  width  regulated  by  the  diameter  of  the  roots. 
Those  for  the  removal  of  the  roots  of  the  superior 
molars,  when  these  are  separated,  have  the  same  form 
of  beaks  as  those  for  the  front  teeth,  but  more  curved, 
to  facilitate  their  approach  to  the  roots.  For  the 
removal  of  these  roots,  it  is  well  to  have  several  pairs 
of  forceps  with  different  degrees  of  curvature,  using, 
in  any  given  case,  those  with  the  least  admissible 
curve, — which  in  a  small  mouth  will  be  considerable, 
while  in  a  large  one  it  will  be  very  slight.  The  same 
forceps  that  are  used  for  the  removal  of  the  front 
inferior  teeth  are  applicable  to  the  removal  of  their 
roots. 

Of  the  different  forms  of  forceps  for  the  removal  of 
the  roots  of  inferior  molars,  those  for  the  extraction 
of  the  roots  before  they  are  separated,  and  while  they 
are  firmly  attached,  have  two  long,  slender,  round, 


402 


EXTRACTION    OF    TEETH. 


curved  beaks,  designed  to  pass  down  deep  between 
and  embrace  the  roots  in  the  bifurcation ;  their  curva- 
ture should  be  almost  a  right  angle,  and  their  handles 

Fig.  110. 


assume  the  form  of  the  ordinary  right  and  left  inferior 
molar  forceps,  already  described  (Fig.  110)  ;  or  if 
but  one  is  used,  the  handle  should  be  straight.  The 
forceps  for  the  remoA^il  of  these  roots  after  they  are 
separated  should  have  the  beaks  of  the  same  form 

•       Fiir.  111. 


as  those  of  the  superior  root  forceps ;  but  the  beaks 
should  be  curved  to  a  right  angle  with  the  handle, 
and  the  handle  be  straight.      (Fig.  111.) 


ELEVATORS. 


403 


ELEVATORS. 

There  are  in  use  variously-formed  instruments 
constructed  on  the  principle  of  the  elevator.  They 
are  made  with  such  points  as  to  take  the  most  thor- 
ough hold  on  the  teeth  or  roots  on  which  they  are 
to  be  used,  and  with  such  curvature  of  shaft  as  to 
enable  them  to  pass  most  readily  to  the  desired  posi- 

Fiff.  112. 


tion.       Some    are    so   formed    at   the    points    as    to 
embrace  the  root  at  the  border  of  the  alveoluS;  using 

Fig.  113. 


the  latter  as  a  fulcrum  (Fig.  112)  ;  others,  to  pass 
between  the  alveolus  and  the  root  (Fig.  113)  ;  others, 
to  cut  through  the  alveolus,  and  thus  approach  the 
root.  All  the  ordinary  elevators  make  a  fulcrum  of 
the  alveolus,  or  of  an  adjoining  tooth ;  but  some  ope- 
rators, in  using  this  instrument,  contrive  to  make  a 
fulcrum  of  the  thumb  or  one  of  the  fingers,  which  is 
the  preferable  way. 


404 


EXTRACTION   OF   TEETH. 


HOOKS. 

These  are  formed  so  that  the  point  will  embrace 
the  root  and  remove  it,  without  resting  on  the  sur- 
rounding parts.      The   root  is  removed    simply  by 

Fig.  114. 


pressure,  applied  in  the  proper  direction.  Of  the 
various  forms  of  this  instrument,  there  are  the  for- 
ward hook,  the  backward  (Fig,  114),  and  the  com- 
pound (Fig.  115),  which  last  includes  the  former  two. 

Fig.  115. 


These  are  valuable  instruments,  but  require  care,  in 
order  to  avoid  injuring  the  surrounding  parts. 


SCREW. 

This  is  a  cone-shaped  instrument,  with  a  very 
definite,  sharp  screw-thread ;  the  manner  of  using 
it  in  the  operation  of  extraction  is,  to  screw  it  into 
the  root.  It  will  be  required  of  various  sizes,  to 
correspond  with   those  of  the  different  roots  to  be 


SCREW. 


405 


extracted.     It  is  commonly  attached  to  the  handle 
by  a  permanent  shaft  (Fig.  116) ;  but  sometimes  it  is 


Fiff.  116. 


made  with  a  square  shaft  fitted  into  a  socket  handle 
(Fig.  117),  by  which  arrangement  the  handle  is  used 
only  to  introduce  the  screw ;  and  this  serves  only  as 
a  support  to  a   frail   root,  the   forceps  being   then 

Fijr.  117. 


brought  to  bear  in  connection  with  it  for  the  removal 
of  the  root.  A  screw-tap  of  the  same  form  as  the 
screw  should  accompany  it. 

When  the  screw  is  combined  with  the  forceps  for 
the  purpose  of  supporting  the  root,  and  preventing  it 
from  crushing  while  it  is  removed  with  the  forceps, 
the  latter  is  of  the  same  form  as  that  of  the  ordinary 
straight  root  forceps,  with  the  shaft  of  the  screw 
attached  in  the  joint.  In  some,  the  screw  is  attached 
with  a  spring  and  ratchet,  so  that  it  can  be  drawn 
out,  seized  between  the  beaks,  and  introduced  into 
the  root;  and  then  these  are  slipped  on  the  root, 
which  they  embrace  and  remove.     In  others,  the 


406 


EXTRACTION    OF   TEETH. 


screw  is  fixed ;  but  the  movable  screw  is  to  be  pre- 
ferred.    (Fig.  118.)     An  arm  attached  by  a  joint, 


Fiff.  118. 


and  bearing  a  pad,  to  rest  as  a  fulcrum  on  the  other 
teeth,  is  sometimes  attached  to  the  shaft  of  the  screw ; 
but  this  is  objectionable,  because  of  its  liability  to 
impede  the  action  of  the  instrument,  and  also  to 
injure  the  adjoining  teeth. 


GUM-LANCET. 

Of  the  various  forms  of  the  gum-lancet,  the  most 
common  is  that  with  the  round  point,  and  with  the 
blade  from  two  to  four  lines  wide,  and  from  half  an 
inch  to  an  inch  long,  attached  to  a  shaft  and  handle, 
the  whole  being  about  six  inches  in  length.  The  in- 
strument should  have  a  keen  edge  on  the  sides,  two 
or  three  lines  from  the  extreme  point.  It  is  some- 
times made  with   the  edge  square  ;  but  the  round 

Fie  119. 


edge  is  the  better  form.     The  edge  is  parallel  with 
the  handle  in  the  ordinary  lancet.     (Fig.  119.)     This 


GUM-LANCET.  407 

form  is  used  for  separating  the  gum  from  the  buccal 
and  palatal  surfaces  of  the  tooth.  A  lancet  with  the 
edge  transverse  to  the  shaft  is  required  for  separating 
the  gum  from  the  proximal  portions  of  the  teeth. 
The  blade  of  this  should  be  of  the  same  general 
form  as  that  already  described,  except  that  it  should 
be  quite  narrow — in  no  case  more  than  two  lines 
wide.     (Fig.  1-0.)     Gum  lancets  are  made  with  the 


blade  set  in  a  socket  on  the  end  of  the  shaft,  so  that 
it  can  be  rotated  and  set  to  any  angle  to  meet  every 
case. 

A  very  ingenious  instrument,  invented  by  Dr. 
Merry,  and  denominated  "  Merry's  Revolving  Gum- 
lancet,"  was  devised  and  constructed  about  fifteen 
years  ago.  This  is  a  very  excellent  instrument — 
superior,  indeed,  to  anything  else  of  the  kind,  at 
least  it  was  at  that  time.  (Fig.  121.)  The  following 
is  a  description  of  it :  "  It  consists  mainly  of  two 
shafts  :  one  is  round  and  small ;  the  other  is  larger, 
part  round,  and  part  octagon.  Just  back  of  the 
spiral  spring  which  curves  down  at  the  lancet  end,  is 
seen  a  piece  connecting  the  two  shafts.  This  piece 
is  soldered  fast  to  the  round  shaft,  while  the  upper 


408  EXTRACTION    OF   TEETH. 

end  of  it  forms  a  collar  in  which  the  round  part  of 
the  larger  shaft  slides  back  and  forth  and  revolves. 

Fig.  121. 


On  the  other  end  of  the  large  shaft  is  seen  a  screw, 
made  by  winding  a  wire  spirally  round  it.  From  the 
small  shaft  arises  another,  but  shorter,  spiral  wire, 
which  fits  into  that  upon  the  larger  shaft.  The  short 
one  may  be  considered  the  nut,  in  which  the  other 
revolves.  The  ends  of  the  short  spiral  are  soldered 
fast  to  the  small  shaft.  If,  then,  the  large  shaft  is 
revolved,  the  screw  on  it,  playing  in  the  nut,  is  made 
to  slide  back  and  forth  accordingly  as  it  may  be 
revolved.  This  motion,  then,  changes  the  direction 
of  the  point  of  the  lancet  to  the  plane  of  the  shafts, 
any  degree  from  a  right  angle  to  a  parallel.  Having 
thus  got  the  inclination  which  is  desired,  the  blade  is 
inserted  into  the  gum  at  the  point  at  which  the  in- 
cision is  to  begin ;  and  as  the  instrument  cuts,  rotate 
the  larger  shaft  slightly,  and  the  blade  will  follow 
the  outline  of  the  tooth  as  it  cuts  round  it." 

THE    METHOD   OF    LANCING    THE    GUMS 

In  all  cases  the  gum  should  be  separated  from  the 
tooth  as  far  as  the  embrace  of  the  forceps  is  to  ex- 


METHOD    OF    LANCING    THE    GUMS.  409 

tend ;  the  lancet  should  pass  close  to  the  tooth,  so  as 
to  make  the  separation  clean  about  its  neck ; — in 
order  to  do  which,  the  lancet  must  be  kept  in  good 
condition  ;  it  should  also  be  passed  freely  between 
the  teeth.  A  complete  separation  of  the  gum  is 
essential  to  a  good  hold  of  the  forceps  on  the  tooth. 
Some  operators,  however,  do  not  use  the  lancet  for 
this  purpose,  but  tear  the  gum  away  by  forcing  the 
forceps  to  its  position  on  the  tooth.  This  method  is 
objectionable  on  several  accounts :  it  causes  the 
patient  much  more  pain  than  with  a  sharp  lancet; 
the  forceps  cannot  thus  be  adjusted  to  the  tooth  with 
so  much  facility ;  there  is  far  more  danger  of  lace- 
rating the  soft  parts,  and  because  of  an  imperfect 
adaptation  of  the  forceps  to  the  tooth,  more  danger 
of  fracturing  it :  and  the  operation  is  always  more 
difficult  of  accomplishment.  In  those  cases  in  which 
the  gum  is  firm  and  dense,  and  would  obstruct  the 
free  passage  of  the  forceps  to  the  proper  position  on 
the  tooth,  it  is  sometimes  necessary  to  make  a  verti- 
cal incision  of  the  gum,  even  after  it  has  been  sepa- 
rated, directly  opposite  the  root.  But  it  is  in  many 
instances  better  to  cut  away  a  portion  of  the  free 
margin  of  the  gum  in  the  extraction  of  roots  that  are 
partially  covered  by  it ;  and  there  is  no  objection  to 
this  method  in  any  case  where  it  may  at  all  facilitate 
the  operation ;  for  this  portion   of  the   gum,  if  let 


410  EXTRACTIO^i    OF    TEETH. 

remain,  is  always  absorbed  or  slougbed  away  after  the 
extraction  of  teeth.  It  is  also  sometimes  necessary 
to  dissect  the  gum  somewhat  from  the  alveolus,  in 
those  cases  in  which  a  deep  hold  on  the  tooth  or  root 
is  required,  and  in  which  the  alveolus  is  either  cut 
away  or  embraced  by  the  forceps.  The  character  and 
condition  of  the  tooth  will  somewhat  modify  the 
extent  to  which  the  gum  lancet  should  be  used. 


EXTRACTION    OF    THE    TEETH. 

In  the  following  remarks  it  is  the  design  to  con- 
sider only  those  principles  obviously  involved  in  the 
extraction  of  the  teeth  with  forceps,  and  in  the 
extraction  of  roots  with  forceps,  elevators  and  screws. 

Superior  Incisors. — After  an  examination,  the  gum 
should  ill  all  cases  be  perfectly  separated  from  the 
neck  of  the  tooth,  up  to  the  border  of  the  alveolus  ; 
this  is  quite  sufficient  if  the  tooth  is  not  too  much 
decayed.  With  the  forceps  already  described  (see 
Fig.  97),  grasp  the  tooth  firmly  at  the  border  of  the 
alveolus  ;  introduce  the  instrument  slowly,  adjusting 
it  carefully  as  it  passes  up  to  the  proper  position ; 
then,  by  a  gradual  movement,  rotate  the  tooth  in  the 
socket,  thus  breaking  up  the  attachment.  All  the 
cylindrical,  single-root  teeth  may  be  luxated  by  a 
rotary  motion.     There  are  occasional  circumstances, 


EXTRACTION    OF    TEETH.  411 

however,  that  render  this  somewhat  difficult — as,  for 
instance,  any  considerable  curvature  of  the  root,  or, 
sometimes,  the  attachment  to  the  outer  plate  of  the 
alveolus  is  so  tirm,  that  it  cannot  be  broken  up  by 
rotary  motion.  Neither  of  these  difficulties  is  usual 
with  the  lateral  incisors,  but  with  the  centrals,  one 
or  other  of  them  is  not  unfrequent.  When  either  of 
them  does  occur,  the  attachment  must  be  broken  up  by 
an  inward  and  outward  movement,  which,  on  account 
of  the  pressure  made  on  the  parts,  is  attended  with 
much  more  pain,  and  far  greater  danger  to  the  con- 
tiguous parts,  than  the  loosening  by  rotary  motion. 

The  roots  of  the  incisors  are  not  difficult  to  remove, 
unless,  being  very  much  decayed,  they  will  not  sus- 
tain the  embrace  of  the  forceps  below  the  border  of 
the  alveolus  ;  and  when  they  are  thus  decayed,  one 
of  the  following  methods  may  be  adopted :  The  gum 
may  be  dissected  from  the  alveolus,  and  the  latter 
cut  away  with  the  thick  cutting  instrument,  so  as  to 
expose  the  root  sufficiently  for  extraction  with  the 
root  forceps  ;  or,  after  the  gum  is  dissected  up,  the 
alveolus  and  the  root  may  be  together  embraced, 
and  the  former  broken  and  removed  with  the  latter. 
This  is  a  rough  and  severe  operation,  though  it  is 
often  adopted.  Or,  an  elevator  of  the  proper  form 
may  be  introduced  between  the  root  and  the  alveolus, 
and  the  root  thus  dislodged. 


! 


412  EXTRACTION    OF   TEETH. 

The  screw,  either  simple  or  compound,  is  a  valuable 
instrument  for  the  removal  of  these  roots.  But  the 
gum  should  be  separated  even  when  the  extraction 
is  to  be  accomplished  with  this.  The  canal  in  the 
root  should  first  be  enlarged  with  a  taper  drill,  of  the 
sam'e  shape  as  the  screw,  till  all  the  softened  dentine 
is  removed.  Then  the  screw,  selected  of  proper 
size,  having  a  very  sharp  thread,  is  introduced,  till  it 
takes  a  strong  hold  in  the  solid  dentine,  especially  if 
it  is  the  simple  screw.  In  some  instances,  while  it  is 
being  introduced,  the  root  will  be  loosened.  In  using 
the  screw  in  connection  with  the  forceps,  it  is  not 
necessary  to  introduce  it  with  the  same  firmness  as 
when  the  screw  alone  is  employed.  In  the  use  of  the 
screw-forceps,  the  screw  is  embraced  in  the  beaks, 
and  introduced;  then  the  forceps  are  passed  up  on 
the  root,  or  between  it  and  the  alveolus,  if  need  be, 
the  screw  serving  to  sustain  the  root  under  the  press- 
ure of  the  forceps.  The  attachment  of  the  root  is 
broken  by  a  rotary,  or  an  inward  and  outward  move- 
ment, as  the  case  may  requu'e. 

Superior  Cuspids. — For  the  removal  of  these  teeth, 
the  central  incisor  or  the  bicuspid  forceps  may  be 
used,  though  usually  the  beaks  of  the  former  are  too 
thin,  and  those  of  the  latter  too  narrow.  The  forceps 
appropriate  for  the  removal  of  these  teeth  have 
broad,  deep,  concave  beaks,  so  as   to   embrace  the 


EXTRACTION    OF    TEETH.  413 

tooth  as  completely  as  possible  ;  and  they  are  thick, 
so  as  to  possess  sufficient  strength.  The  gum  being 
separated,  and  the  forceps  adjusted  on  the  tooth,  the 
attachment  is  broken  up,  either  by  an  inward  and 
outward  or  by  a  rotary  movement ;  the  former  will 
be  far  more  frequently  brought  into  requisition,  since 
these  teeth  are  generally  so  firmly  attached  that  they 
cannot  be  loosened  by  the  latter ;  but  the  skillful 
fend  experienced  operator  will  often  combine  the  two, 
with  the  happiest  effect.  These  teeth  have  larger 
roots  than  anv  others  in  the  mouth,  and  the  alveolar 
process,  especially  the  outer  plate,  closely  invests 
them ;  and  thus  they  are  very  firmly  fixed  in  the 
sockets,  and  are  also  more  frequently  found  curved 
than  the  roots  of  the  incisors.  Often,  in  extraction 
of  the  cuspids,  a  portion  of  the  outer  wall  of  the  alve- 
olus is  broken  off",  and  comes  away  with  the  tooth. 
But  this  accident  is  not  attended  with  any  serious 
results ;  indeed,  in  the  preparation  of  the  mouth  for 
artificial  teeth,  it  is  desirable  that  it  be  broken  away 
somewhat. 

The  movement  in  the  extraction  of  a  tooth  should 
alw'ays  be  very  deliberate — never  sudden  and  vio- 
lent. A  very  good  criterion  in  regard  to  the  rapidity 
of  movement  is,  that  the  eye  should  follow  and  dis- 
tinctly recognize  every  motion  of  the  forceps,  the 
tooth,  and  the  contiguous  parts. 


414  EXTRACTION    OF   TEETH. 

The  removal  of  the  roots  of  these  teeth  is  far  more 
difficult  than  that  of  the  incisors.  Frequently  the 
gum  has  to  be  separated  up  two  or  three  lines  on  the 
alveolus,  and  the  latter  broken  in  with  the  forceps, 
before  the  root  is  removed.  The  compound  screw  is 
often  very  A'aluable  in  the  removal  of  these  roots, — 
the  simple  screw  not  commonly  being  of  much  avail, 
since  the  force  necessary  to  extract  the  root  is  gene- 
rally so  great  that  the  screw  alone  will  not  take  a 
sufficiently  firm  hold  to  accomplish  it.  The  elevator 
is  not  a  very  efficient  instrument  in  the  removal  of 
these  roots. 

Superior  Bicuspids. — For  the  removal  of  the  bicus- 
pid teeth  of  both  sides,  one  pair  of  forceps  is  quite 
sufficient.  (See  Fig.  99.)  These  forceps  are  without 
any  curve ;  though  in  a  small  mouth,  for  the  second 
bicuspids,  a  slight  anterior  curve  would  be  desirable, 
since  it  would  admit  the  instrument  to  a  better  posi- 
tion on  the  tooth.  These  forceps  properly  adjusted 
on  the  tooth,  according  to  the  directions  already 
given,  the  attachment  is  broken  up  by  an  inward  and 
outward  movement,  carried  just  to  the  extent  neces- 
sary to  accomplish  the  object ;  and  then  traction  is 
applied  to  remove  the  tooth  from  the  socket.  This 
application  of  the  force  is  specially  adapted  to  the 
first  bicuspids.  Rotary  motion  should  be  very  seldom 
applied  to  these  teeth,  because  their  points  generally 


EXTRACTION    OF   TEETH.  415 

terminate  in  a  bifurcation,  and  it  is  impracticable  thus 
to  detach  them  without  breaking  off  at  least  one  of 
the  roots  ;  and  where  they  do  not  bifurcate,  they  are 
so  much  compressed  as  generally  to  forbid  such  a 
force.  Occasionally,  however,  there  is  but  one  root, 
and  this  is  nearly  cylindrical,  as  will  be  indicated  by 
the  cylindrical  form  of  the  crown  and  neck  of  the 
tooth;  and  in  such  cases  the  rotary  may  be  combined 
with  the  inward  and  outward  motion.  The  root  of  the 
second  bicuspid  commonly  has  no  bifurcation,  and  is 
usually  somewhat  compressed ;  and,  in  general,  the 
rotary  motion  may  be  combined  with  the  inward  and 
outward  in  its  extraction.  There  is  occasionally,  how- 
ever, some  curvature  to  the  roots  of  these  teeth ;  but 
very  seldom  is  it  sufficient  to  cause  any  difficulty  in 
their  removal.  The  skillful  and  experienced  operator 
will  in  most  cases  determine  very  accurately  the 
size,  shape,  and  position  of  the  roots  by  the  peculiar- 
ities of  the  crown ;  and  the  attention  of  the  young 
practitioner  should  be  directed  very  closely  to  this 
point,  till  he  is  able  to  arrive  at  accurate  conclusions. 
For  the  removal  of  these  teeth,  there  are  forceps  with 
thick,  peculiarly-formed  beaks,  constructed  to  take 
advantage  of  the  conical  shape  of  the  roots.  The  in- 
strument is  placed  on  the  tooth  at  the  border  of  the 
alveolus,  or,  if  need  be,  a  little  beyond  it ;  and  then, 
the  process  having  been  first  cut  away,  firm  compres- 


416  EXTRACTION    OF   TEETH. 

sion  is  made  on  the  handle  of  the  instrument,  and 
thus  great  pressure  on  two  sides  of  the  root, — which 
are  relatively  as  two  inclined  planes, — by  which  the 
tooth  is  forced  directly  from  its  socket,  without  either 
the  oscillating  or  the  rotary  motion.  This  instrument 
is  rarely  ever  applicable  to  the  removal  of  any  other 
teeth  than  the  second  bicuspids,  and  occasionally  the 
central  incisors,  and  then  only  when  the  roots  are 
very  tapering.  The  roots  of  the  bicuspids,  especially 
the  second,  are  usually  not  difficult  to  remove.  Some- 
times, however,  the  first  bicuspids  have  two  well- 
formed  roots,  somewhat  divergent,  that  are  difficult 
to  remove,  especially  if  the  decay  has  eaten  away 
till  there  is  little  of  the  tooth  left  for  the  instrument 
to  take  hold  upon.  But,  frequently,  if  one  of  the 
contiguous  teeth  is  absent,  a  lateral  seizure  will  re- 
move the  root  at  once. 

Root  forceps  with  narrow,  thin  beaks,  which  may 
be  readily  forced  between  the  root  and  the  alveolus, 
are  very  valuable  for  the  extraction  of  all  small 
roots. 

The  screw,  whether  simple  or  compound,  is  not 
applicable  to  the  extraction  of  the  roots  of  the 
bicuspids. 

A  bicuspid  will  sometimes  stand  somewhat  out  of 
the  true  circle,  and  the  contiguous  teeth  approximate 
so  that  it  will  not  pass  between  them.     In  such  a 


EXTRACTION    OF   TEETH.  417 

case,  the  principal  part  of  the  movement  for  its  de- 
tachment should  be  in  the  direction  of  its  inclination. 
The  cuspid  teeth  are  sometimes  found  in  the  same 
condition,  and  a  similar  application  of  force  for  their 
removal  is  to  be  made ;  indeed,  this  method  is  appro- 
priate to  all  cases  where  the  teeth  stand  out  of  a 
proper  position,  and  the  contiguous  teeth  impinge  on 
the  space. 

Superior  Molars. — The  first  and  the  second  superior 
molars  have  each  three  roots,  one  palatal,  and  two 
buccal ;  the  palatal  being  the  largest  and  longest, 
and  the  anterior  buccal  larger  than  the  posterior. 
The  palatal  root  diverges  very  considerably  from  the 
axis  of  the  tooth,  while  the  buccal  are  often  parallel 
with  it  and  with  each  other ;  but  they  sometimes 
diverge  in  both  directions.  Occasionally,  the  diver- 
gence of  some  or  all  of  these  roots  is  so  great,  that 
they  cannot  pass  out  of  the  socket  without  either 
fracturing  the  alveolus  or  breaking  off  one  or  more  of 
the  roots.  On  the  contrary,  there  is  sometimes  such 
a  convergence  of  the  buccal  roots,  that  the  interven- 
ing portion  of  bone  is  necessarily  brought  away  with 
the  tooth.  Indeed,  the  three  roots  are  sometimes 
found  all  in  contact,  forming  an  irregular  conical  root ; 
but  this  is  a  condition  of  unnatural  development. 

The  appropriate  forceps  being  firmly  fixed  on  the 
tooth,  an  outward  and  inward  movement  is  applied, 


418  EXTRACTION    OF   TEETH. 

and  traction  at  the  same  time.  In  the  examination 
of  these  teeth,  to  ascertain  the  force  necessary  for 
their  removal,  two  particulars  have  to  be  considered  : 
the  firmness  of  the  attachment,  and  the  position  and 
inclination  of  the  roots.  When  these  teeth,  as  they 
occasionally  do,  stand  somewhat  outside  of  the  cor- 
rect position,  great  care  must  be  exercised  in  their 
removal,  especially  if  the  contiguous  teeth  impinge. 
In  small  mouths,  the  contiguous  impinging  tooth  is 
liable  to  be  injured  by  the  pressure  in  extraction;  but 
this  injury  may  be  avoided  by  directing  the  pressure 
backward.  Commonly,  the  first  effort  made  to  break 
up  the  attachment  should  be  outward,  except  where 
the  tooth  stands  inside  the  circle,  or  where  it  is 
decayed  very  much  on  its  inner  side,  while  its  outer 
remains  firm.  In. those  cases  in  which  the  roots 
diverge  so  much  that  they  will  not  pass  out  of  the 
socket  without  tearing  away  some  of  the  wall  of  the 
alveolus,  it  would  be  impossible  to  break  up  the 
attachment  by  an  inward  movement,  for  the  palatal 
root  braces  the  tooth,  and  the  inner  process  is  very 
strong  and  unyielding.  AVhere  a  molar  has  decayed 
on  its  proximal  sides,  and  the  contiguous  teeth  en- 
croach on  it,  so  that  it  cannot  pass  out  directly 
between  them,  it  must  either  be  cut  away  with  the 
chisel,  file  or  disk  till  it  is  small  enough  to  pass  out, 
or  be  drawn  from  between  them. 


EXTRACTION    OF   TEETH.  419 

The  decay  on  the  buccal  or  palatal  sides  often 
extends  below  the  gum,  and  even  below  the  border  of 
the  alveolus ;  or  there  may  be  extensive  softening 
of  the  dentine  of  the  crown ;  in  either  case,  the  gum 
and  process  must  be  cut  away  sufficiently  to  admit  a 
firm  hold  on  the  root  where  it  is  strong  enough  to 
sustain  the  embrace  of  the  forceps. 

Extraction  of  Roots. — The  extraction  of  the  roots 
of  the  superior  molars  is  not  attended  with  much 
difficulty  when  they  are  separated  by  decay,  or  are 
easily  broken  apart ;  the  method  then  is  the  same  as 
for  single  roots.  They  should  be  deeply  embraced 
with  the  curved,  sharp-pointed  root  forceps  (see  Fig. 
104),  and  rotated  to  break  up  the  attachment,  trac- 
tion being  applied  at  the  same  time.  It  is  very 
rarely  necessary  to  resort  either  to  the  elevator  or  to 
the  screw  for  the  removal  of  these  roots.  The 
greatest  difficulty  is  experienced  when  the  bifurca- 
tion is  deep  and  the  roots  all  adhere  firmly  together. 
In  such  case,  the  same  force  is  required  for  their 
removal  as  before  the  crown  was  decayed  ofi".  The 
root  forceps,  shown  in  Fig.  101,  can  be  very  effect- 
ively used  in  the  extraction  of  these  roots.  The 
round,  sharp  beak  is  passed  between  the  buccal  roots, 
the  other  beak  embracing  the  palatal ;  and  with  this 
hold,  by  an  inward  and  outward  movement,  the  root 
is  removed.     These  forceps  are  not  applicable  where 


420  EXTRACTION    OF   TEETH. 

there  is  but  one  large  conical  root.  For  the  removal 
of  roots  of  this  form,  the  ^visclom-tooth  forceps,  or 
those  with  similar  beaks,  are  required.  When  it  is 
necessary  to  dissect  off  the  gum,  and  cut  away  the 
process,  in  order  to  obtain  a  firm  hold  of  the  root,  this 
should  be  done  in  preference  to  crushing  in  the  pro- 
cess with  forceps — except,  indeed,  it  may  be  the  case 
of  a  very  irritable  patient,  who  will  not  tolerate  a  pro- 
tracted operation,  in  which  case  it  is  better  to  com- 
plete the  operation  at  a  single  effort. 

Third  Molars. — There  is  not  usually  much  difficulty 
attending  the  extraction  of  these  teeth.  The  appro- 
priate forceps  for  this  purpose  (see  Figs.  102  and  107) 
have  two  large  single-concave  beaks,  so  formed  as  to 
embrace  the  neck  of  the  tooth,  without  any  reference 
to  the  bifurcation  or  the  number  and  position  of  the 
roots.  Ordinarily,  the  attachment  of  these  teeth  is 
broken  up  by  the  inward  and  outward  movement;  but 
where  a  single,  round,  conical  root  is  clearly  indicated, 
the  rotary  movement  would  be  preferable,  or  the 
rotary  in  conjunction  with  the  inward  and  outward. 
These  teeth  sometimes  stand  out  of  the  true  position, 
more  frequently  inclining  outward,  as  already  sug- 
gested in  another  place ;  and  the  direction  of  the 
force  for  their  extraction  will  correspond  with  this 
inclination. 

Sometimes  these  teeth  are  very  difficult  to  extract ; 


EXTRACTION    OF    TEETH.  421 

and  this  difficulty  is  dependent  on  the  following  cir- 
cumstances :  first,  an  anterior  inclination  of  the  tooth, 
so  that  it  stands  at  a  considerable  angle  with  the 
adjoining  tooth,  and  in  contact  with  its  posterior 
proximal  surface,  the  posterior  border  of  the  process 
being  thick  and  firm,  and  extending  down  full  on 
the  crown  of  the  tooth ;  and  second,  the  existence  of 
several  roots,  with  great  divergence,  irregularity,  and 
curvature.  The  removal  of  a  tooth  in  the  first  of 
these  conditions  is  often  a  very  protracted  operation, 
fraught  with  much  pain  to  the  patient  and  consider- 
able labor  to  the  operator.  Such  preparation  must 
be  made  as  will  permit  a  free  egress  of  the  tooth 
from  the  socket,  before  an  effort  is  made  for  its 
extraction.  This  is  effected  either  by  cutting  away 
the  portion  of  process  behind  the  tooth,  so  that  it  may 
be  forced  backward  sufficiently  to  let  it  pass  out  of 
the  socket,  or  by  cutting  away  enough  from  the 
anterior  portion  of  the  tooth ;  or,  if  the  posterior 
proximal  surface  of  the  second  molar  is  decayed,  it 
may  be  quite  as  well,  and  more  convenient,  to  cut 
this  down  so  as  to  permit  the  ready  removal  of  the 
tooth. 

Physic's  forceps  can  be  used  very  effectively  for 
the  extraction  of  these  teeth  when  they  occupy  such 
a  position,  provided  the  root  is  straight,  or  has  a  pos- 
terior curvature ;  but  if  there  is  an  anterior  curvature, 


422  EXTRACTION    OF   TEETU. 

the  tooth  is  most  difficult  to  extract,  and  Physic's 
forceps  would  be  AvhoUy  inefficient,  except  to  break 
off  the  tooth.  In  such  case,  the  posterior  portion  of 
the  process  should  be  cut  away  as  much  as  possible. 
Physic's  forceps  are  frequently  employed  for  the 
removal  of  these  teeth  when  they  occupy  a  correct 
position;  but  their  use  is  somewhat  objectionable, 
especially  in  the  following  respects.  The  instrument 
acts  first  on  the  principle  of  a  wedge,  being  forced 
between  the  teeth ;  and  then  on  that  of  a  lever,  the 
second  molar  being  the  fulcrum ;  and  hence,  when  it 
is  employed,  the  second  molar  must  always  be  pre- 
sent, and  is  liable  to  injury  from  the  pressure,  which 
may  do  violence  to  the  periosteum,  or  fracture  and 
scale  off  portions  of  the  enamel.  But  if  the  first 
molar  is  absent,  there  is  almost  as  much  liability,  with 
the  Physic's  forceps,  of  loosening  the  second  as  of 
extracting  the  third.  Indeed,  it  is  always  objection- 
able to  use  a  sound  tooth,  under  any  circumstances, 
as  a  fulcrum  for  an  extracting  instrument. 

A  wisdom-tooth  the  roots  of  which  are  irregular  in 
number,  inclination,  and  curvature,  should  be  grasped 
firmly,  and  an  oscillating  force  applied  sufficient  to 
remove  it  from  its  socket.  There  is  nothing  per- 
taining to  the  removal  of  the  roots  of  these  teeth 
that  involves  any  different  principle  or  application  of 
instruments  from  that  given  for  the  removal  of  the 


EXTRACTION    OF    TEETH.  423 

teeth  themselves.  The  anterior  inclination,  which  so 
often  renders  the  whole  tooth  difficult  of  extraction, 
very  seldom  affects  the  removal  of  the  roots.  These 
are,  in  general,  easily  extracted  with  the  common 
curved  root-forceps. 

Imferior  Incisors. — In  the  extraction  of  these  teeth, 
either  of  the  forceps  described  for  the  purpose  may  be 
employed.  The  beaks  should  be  quite  narrow  and 
thin  (see  Fig.  103).  The  instrument  well  fixed  on 
the  tooth,  the  attachment  is  broken  up  by  an  inward 
and  outward  movement,  the  rotary  being  seldom 
applicable,  since,  in  general,  the  roots  are  flattened, 
and  in  many  cases  quite  thin,  so  as  to  be  incapable  of 
turning  in  the  socket.  Care  must  be  exercised  in 
the  oscillating  movement,  and  especially  where  the 
tooth  to  be  extracted  stands  out  of  the  proper  position, 
and  the  contiguous  teeth  incline  together;  though  this 
is  of  little  consequence  where  the  teeth  are  all  to  be 
removed.  When  the  crowns  of  these  teeth  are  short 
and  thick,  the  roots  are  shorter,  thicker,  more  coni- 
cal, and  more  nearly  cylindrical ;  and  in  the  extrac- 
tion of  such  the  rotary  may  be  combined  with  the 
oscillating  movement. 

There  is  seldom  any  superadded  difficulty  in  the 
removal  of  the  roots  of  these  teeth,  the  same  instru- 
ments and  movements  being  applicable  as  for  the 
removal  of   the   teeth   themselves.      The    only   dif- 


424  EXTRACTION    OF   TEETH. 

ference  in  any  respect  is,  that  where  the  teeth  are 
decayed  off  far  down,  the  forceps  should  be  forced 
down  on  the  process,  in  order  to  obtain  a  firm  hold  on 
the  root.  Neither  the  elevator  nor  the  screw  is  ever 
required  for  the  removal  of  these  roots. 

Inferior  Cuspids. — These  teeth  may  be  removed 
with  the  inferior  bicuspid  forceps  of  the  right  side, 
though  an  instrument  of  the  same  general  form, 
but  of  less  curvature,  would  be  preferable,  since 
with  such  the  required  movement  for  breaking  up 
the  attachment  could  be  more  easily  given.  They 
comitfonly  have  long,  round,  conical  roots,  not  so 
large  as  those  of  the  superior  cuspids,  nor  so  diffi- 
cult to  extract,  seldom  having  any  curvature,  and 
thus  being  susceptible  of  detachment  by  the  rotary 
motion.  They  often  stand  so  much  anterior  to  the 
true  circle,  that  an  attempt  to  thrust  them  inward 
would  be  liable  to  break  or  loosen  the  lateral  incisors. 
Their  situation,  as  indeed  that  of  all  teeth,  should  be 
strictly  attended  to  before  any  attempt  is  made  to 
remove  them. 

The  crowns  of  these  teeth  decay  off,  and  leave  the 
roots  standing,  far  more  frequently  than  do  those  of 
the  superior  bicuspids.  But  there  is  no  difficulty  in 
the  removal  of  their  roots,  and  the  only  indication  is, 
when  they  are  deeply  decayed,  to  pass  the  forceps  far 
down  on  them,  either  first  cutting  away  the  process 


EXTRACTION    OF   TEETH.  425 

or  embracing  it,  as  the  circumstances  may  warrant, 
the  former  method  being  preferable.  After  the  root 
is  extracted,  the  fractured  pieces  of  process,  if  any, 
should  be  removed. 

A  long,  tapering  screw  may  sometimes  be  advan- 
tageously used  for  the  extraction  of  these  roots,  when 
they  are  decayed  so  deejaly  that  an  extensive  break- 
ing away  of  the  process  would  be  incident  to  their 
removal  with  the  forceps.  The  elevator,  however,  is 
rarely  ever  called  into  requisition  here. 

Inferior  Bicuspids. — These  teeth,  two  in  number 
on  each  side,  have  but  one  root  each,  and  that 
generally  round,  or  nearly  so,  and  not  so  long  as 
that  of  the  cuspids,  and  have  less  diameter  at 
the  neck  than  they.  They  require,  in  extraction, 
forceps  for  each  side,  as  already  described  (see  Fig. 
105).  They  may  be  removed  either  by  the  rotary 
or  by  the  inward  and  outward  movement,  or  both 
combined.  With  the  handle  of  the  forceps  thrown 
very  far  out  of  a  line  with  the  axis  of  the  tooth, 
it  is  always  more  difficult  to  be  rotated  accurately 
in  its  socket ;  a  straight  instrument  is  best  for 
the  rotary  motion.  In  the  removal  of  these  teeth 
from  the  right  side,  when  the  mouth  is  small,  care 
should  be  taken  that  too  much  pressure  is  not  made 
against  the  anterior  tooth.  This  accident  is  more 
liable  to  happen  in  the  removal  of  the  second  bicus- 


426  EXTRACTION   OF   TEETH. 

pid  than  in  that  of  the  first,  and  especially  if  the 
mouth  cannot  be  opened  wide.  As  the  tooth  comes 
out,  the  forceps  are  liable,  without  some  attention,  to 
strike  the  superior  teeth,  and  in  this  way  fracture 
them  or  scale  off  their  enamel.  In  many  cases,  for- 
ceps with  a  forward  and  an  outward  curvature  com- 
bined would  be  very  desirable,  for  facility  of  ap- 
proaching the  tooth ;  Hut  with  such  a  complication 
of  curves,  the  operator  loses  control  of  the  instru- 
ment. 

In  the  removal  of  the  bicuspids  of  the  left  side, 
there  is  little  or  no  liability  to  undue  pressure  against 
the  anterior  teeth  ;  and  in  their  extraction  the  move- 
ment should  be  mainly  inward  and  outward,  since 
the  great  curvature  of  the  forceps  renders  a  rotary 
motion  very  difficult  and  uncertain.  There  is  also 
danger  of  striking  the  upper  teeth,  especially  if  the 
tooth  to  be  extracted  conies  out  with  less  effort  than 
the  operator  anticipated — an  accident  that  sometimes 
befalls  the  most  skillful  and  discriminating.  The 
first  and  the  second  inferior  bicuspids  are  removed 
with  about  equal  facility. 

Occasionally,  though  seldom,  these  teeth  have  two 
distinct,  well-defined  roots — a  condition  that  cannot 
be  determined  by  the  form  of  the  crown,  or  by  any 
other  visible  indication ;  and  one  tooth  alone  will 
sometimes  be  found  with  this  peculiarity.     The  re- 


EXTRACTION    OF   TEETH.  427 

moval  of  the  roots  of  these  teeth  is  not  attended  with 
much  difficulty,  the  main  consideration  being  to 
obtain  a  deep,  strong  hold  on  them,  and  then  apply 
a  firm,  steady  movement. 

Inferior  Molars. — These  teeth  commonly  have  two 
roots,  a  posterior  and  an  anterior,  the  latter  being  the 
largest,  and  frequently  the  longest.  The  roots  have 
different  inclinations  to  the  axis  of  the  tooth,  being  in 
some  cases  divergent  from,  and  in  others  parallel  with 
it,  and  in  others  convergent,  or  curved  together  so  that 
their  points  almost  meet.  The  forms  of  the  crowns  will 
give  some  indication  of  the  inclinations  of  the  roots. 
If  the  former  are  short,  the  latter  are  so,  and  vice  versa; 
if  the  diameter  of  the  crown  is  about  the  same  at  the 
masticatory  surface  and  the  neck,  the  roots  do  not 
diverge ;  if  the  crown  is  long,  and  of  uniform 
diameter,  the  roots  will  be  either  parallel  or  con- 
vergent ;  and  if  the  angles  on  the  crown  are  not 
sharp  and  well  defined,  the  roots  most  probably  curve 
together  at  the  points.  If,  however,  the  angles  formed 
by  the  masticatory  and  lateral  surfaces  of  the  teeth  are 
sharp  and  well  defined,  the  roots  generally  diverge. 

Forceps  adapted  to  each  side  are  required  for  the 
removal  of  these  teeth.  These  forceps  have  a  promi- 
nence, or  point,  in  the  centre  of  the  beaks,  to  pass 
into  the  bifurcation ;  and  in  separating  the  gum,  it  is 
important  to  dissect  it  away,  and,  if  need  be,  even 


428  EXTRACTION    OF   TEETH. 

cut  away  the  margin  of  the  process,  so  that  the  bifur- 
cation may  be  well  exposed,  to  admit  the  forceps  to 
a  proper  position  on  the  tooth,  without  obstruction. 
The  tooth  being  firmly  grasped  in  the  proper  manner 
by  the  forceps,  is  moved  gradually,  but  steadily, 
inward  and  outward,  to  break  up  the  attachment, 
and  then  drawn  from  its  socket.  In  the  removal  of 
these  teeth  from  the  right  side  with  the  ordinary  for- 
ceps, there  is  great  danger  of  undue  pressure  on  the 
anterior  contiguous  teeth ;  this  is  to  be  avoided  by 
directing  the  pressure  backward  in  the  operation. 
And  there  is  also  danger  of  injuring  the  upper  teeth 
with  the  forceps ;  this  may  be  obviated  by  wrap- 
ping the  point  of  the  instrument  with  a  small  napkin. 
In  the  removal  of  the  inferior  molars  of  the  left 
side,  the  application  of  force  is  the  same — an  inward 
and  outward  movement — but  the  handles  of  the  for- 
ceps occupy  different  relntive  positions  to  the  teeth 
to  be  extracted — passing  directly  out  at  the  front  of 
the  mouth  instead  of  at  one  side.  In  consequence 
of  this  arrangement,  the  operator  cannot  exert  the 
same  force  on  them  as,  with  the  proper  forceps,  on 
those  of  the  right  side.  Very  little  traction  can  be 
employed  in  connection  with  the  oscillating  move- 
ment, but  the  attachment  must  be  almost  wholly 
broken  up  before  beginning  to  lift  the  tooth  from  the 
socket.     But  in  extracting  the  teeth   on  the  right 


I 


EXTRACTION    OF   TEETH.  429 

side  with  the  proper  forceps,  traction  is  always  com- 
bined with  the  inward  and  outward  movement. 

In  the  extraction  of  the  roots  of  these  teeth,  little 
difficulty  is  experienced  after  the  decay  has  proceeded 
so  far  as  to  effect  their  separation.  They  are  then 
embraced  with  the  appropriate  forceps,  and  removed 
as  single  roots  are  elsewhere.  These  forceps  have 
narrow,  thin,  sharp  beaks,  turned  to  almost  a  right 
angle.  With  them  the  root  is  embraced  and  moved 
inward  and  outward  till  loosened,  and  then  removed. 
When  the  mouth  is  large,  and  can  be  opened  wide, 
the  slightly  curved  root  forceps  are  convenient,  and 
the  rotary  movement  may  be  employed  with  them,  if 
the  roots  are  not  very  much  curved,  flattened,  or 
firmly  set.  The  removal  of  these  roots  is  more  diffi- 
cult when  the  bifurcation  is  low  down,  and  the  roots 
remain  firmly  attached  together,  and  especially  when 
they  diverge.  If  the  bifurcation  is  not  too  low,  and 
the  attachment  not  too  firm,  the  roots  may  be  sepa- 
rated with   the  separating  forceps    (Fig.   122),  and 

Fig.  122. 


then  removed  singly,  as  in  other  cases.     This  is  the 
preferable   method  when  there  is  much  divergence ; 


430  EXTRACTIOX    OF   TEETH. 

but  if  the  roots  cannot  be  separated,  they  may  be 
extracted  with  the  forceps  shown  in  Fig.  122.  The 
round,  curved,  sharp  beaks  are  passed  down  between 
the  roots,  and  the  whole  is  removed  at  once  ;  the 
attachment  being  broken  up  on  the  principle  already 
described. 

These  teeth  sometimes  have  but  one  large,  round, 
conical  root ;  and  there  is  seldom,  if  ever,  enough 
curvature  of  the  roots  to  render  extraction  difficult. 
The  ordinary  inferior-molar  forceps  are  not  well 
adapted  for  the  purpose,  for  the  central  points  of 
their  beaks  will  prevent  a  perfect  adaptation.  The 
broad,  single-concave  beaked  forceps  are  best  adapted, 
the  curves  and  general  forms  of  which,  except  the 
beaks,  are  the  same  as  those  represented  in  Fig.  107. 
The  removal  of  teeth  having  roots  of  this  kind  is  easily 
accomplished.  Rotary  movement  would  be  applicable 
here  if  the  exact  form  of  the  root  could  be  ascertained 
before  extraction ;  but  it  is,  in  general,  the  safest  course 
to  employ  the  inward  and  outward  movement. 

Inferior  Third  Molars. — These  teeth  require  for 
their  removal  the  broad,  single-concave  beaked  for- 
ceps, the  benks  curved  at  a  right  angle  with  the 
handle,  and  the  handle  straight.  This  instrument 
fixed  deeply  and  firmly  on  the  tooth,  the  attachment 
is  to  be  broken  up  by  the  inward  and  outward  move- 
ment.     These,  more   frequently  than   the    superior 


EXTRACTION    OF    TEETH.  431 

third  molars,  stand  out  of  the  proper  position ;  their 
variations  and  the  manner  of  obviating  the  attendant 
difficulties,  however,  being  about  the  same — at  least, 
so  far  as  deviation  is  concerned.  Physic's  forceps 
may  be  used  here  with  greater  facility  than  on  the 
upper  teeth. 

These  teeth  frequently  exhibit  but  a  very  small 
portion  of  the  crown  through  the  gum.  Being 
erupted  with  an  anterior  inclination,  the  tooth  comes 
in  contact  with  the  posterior  portion  of  the  second 
molar,  and  is  thus  checked  in  its  external  develop- 
ment. Thus  the  crown  is  left  partially  covered  with 
the  gum,  which  frequently  inflames,  and  even  suppu- 
rates, remaining  in  that  condition  for  a  considerable 
time,  to  the  great  annoyance  of  the  patient.  Such 
teeth  are  difficult  to  remove  ;  first,  because  of  their 
inclination  and  contact  with  the  second  molar ;  and 
secondly,  because  the  crown  is  more  than  half  below 
the  borders  of  the  thick,  firm  alveolus,  rendering  it 
impossible  to  obtain  a  firm  hold  of  the  tooth  without 
cutting  away  a  portion  of  the  alveolus.  In  such 
cases,  it  is  generally  best  to  make  a  free  excision  of 
the  alveolus  all  round  the  tooth,  sufficient  to  permit 
its  easy  removal. 


432  EXTRACTION    OF   TEETH. 


EXTRACTION    PREPARATORY    TO    THE   INSERTION    OF 
ARTIFICIAL    DENTURES. 

Whenever  there  is  a  number  of  teeth  to  be  re- 
moved, the  method  and  the  duration  of  the  operation 
will  depend  on  the  following  circumstances : 

First.  The  number  to  be  removed. 

Second.  The  firmness  of  their  attachment. 

Third.  The  patient's  power  of  endurance. 

Fourili.  The  manner  in  which  the  immediate  parts 
are  affected. 

Where  the  number  to  be  removed  is  considerable, 
and  the  attachment  feeble,  or  not  very  firm,  and  the 
patient's  power  of  endurance  good,  the  extraction 
may  be  as  rapid  as  is  consistent  with  efficiency.  In 
many  such  cases,  from  three  to  six  teeth  may  be 
removed,  without  any  relaxation  by  the  operator  of 
his  hold  on  the  parts  with  the  left  hand.  This  is 
generally  practicable  with  the  front  teeth  of  the 
lower,  and  frequently  with  those  of  the  upper  jaw ; 
but  it  is  not  proper  to  remove  more  than  three  or 
four  of  the  molar  teeth  without  respite,  even  when 
they  are  quite  loose,  or  have  but  a  feeble  attachment 
in  the  socket.  The  gum  should  of  course  be  well 
separated  previously  to  the  operation.  Only  so  many 
teeth  should  be  removed  at  one  sitting  as  the  nervous 


CONDITIONS    TO    BE    OBSERVED    IN    EXTRACTION,       433 

system  will  allow  without  too  great  a  shock.  In 
many  instances,  however,  it  is  practicable,  so  far  as 
this  is  concerned,  to  remove  at  once  all  the  teeth  in 
the  mouth.  In  the  extraction  of  a  large  number, 
those  most  easily  removed  should  be  first  taken,  so 
as  by  degrees  to  bring  the  patient  to  the  more  severe 
operations.  If  there  is  a  manifest  hemorrhagic 
diathesis — a  disposition  to  bleed  freely  from  the 
capillaries,  as  well  as  from  the  larger  vessels — but 
two  or  three  teeth  should  be  removed  at  a  sitting, 
lest  uncontrollable  hemorrhage  ensue. 

After  all  the  teeth  are  removed  from  one  or  both 
of  the  jaws,  the  gums  and  alveolus  should  undergo  a 
trimming  process  :  all  detached,  flabby,  or  prominent 
portions  of  the  gums  should  be  dissected  off;  the 
whole  ridge  made  uniform ;  all  loose  portions  of  the 
alveolus  removed  ;  all  the  prominent  points  and  sharp 
edges  cut  down  ;  and  the  whole  border  of  the  process 
rendered  as  smooth  and  even  as  possible.  By  this 
means,  the  healing  of  the  parts  is  facilitated,  and  they 
assume  the  desired  condition  and  form  in  much  less 
time,  and  with  far  less  soreness  and  inconvenience. 


CONDITIONS    TO    BE    OBSERVED    IN    EXTRACTION. 

Such   conditions  are  often  found  to   exist  in  tlie 
system  as  indicate  the  necessity  of  great  care  in  the 


434  EXTRACTION    OF   TEETH. 

operation,  or  of  jDrior  treatment,  or  forbid  the  extrac- 
tion of  the  teeth  altogether.  Of  these  conditions,  the 
following  are  some  of  the  more  obvious  : 

Extreme  debility. 

Great  nervous  irritability. 

Excessive  local  inflammation,  especially  where  it 
tends  to  other  parts. 

Much  irritability  of  the  parts  intimately  connected 
with  the  teeth. 

Pregnancy  and  all  uterine  irritations. 

A  tendency  to  epilepsy. 

In  many  cases,  where  there  is  great  debility,  so 
painful  an  operation  as  the  extraction  of  a  tooth  will 
cause  'extreme  and  sometimes  alarming  prostration. 
This,  however,  may  be  anticipated  by  prior  invigo- 
rating treatment,  continued  till  strength  and  tone  are 
obtained  sufficient  to  endure  the  operation.  This 
treatment  may  occupy  considerable  time,  while  an 
urgent  case  may  arise,  in  which  the  removal  of  the 
offending  tooth  is  immediately  demanded,  in  which 
case  it  is  proper  to  administer  stimulants — brandy  or 
wine,  or  such  as  the  case  may  seem  to  require.  By 
such  means  the  system  may  be  so  invigorated  as  to 
withstand  the  shock  of  the  operation  with  compara- 
tive fortitude. 

There  is  in  some  cases  a  highly  irritable  condition 
of  the  nervous  system,  that  almost  absolutely  forbids 


CONDITIONS   TO    BE    OBSERVED    IN    EXTRACTION.       435 

the  extraction  of  teeth,  convulsions  being  sometimes 
produced  in  such  cases  by  a  simple  operation.  This 
remark  does  not  of  course  apply  to  facial  neuralgia, 
that  may  be  either  partially  or  wholly  produced  and 
kept  up  by  diseased  teeth ;  neither  general  nor  local 
neuralgia  would  be  aggravated  by  an  operation  of 
this  kind.  Accompanying  general  nervous  irrita- 
bility, there  is  usually  excessive  dread  of  an  opera- 
tion, such  as  to  occasion  rapid  prostration — even 
greater  and  more  rapid  than  that  caused  by  the  ope- 
ration itself.  In  such  cases,  if  the  extraction  is 
effected  immediately,  it  will  give  relief;  but  where 
the  excitement  has  been  very  high,  and  the  tension 
for  some  time  great,  the  depression  after  the  opera- 
tion will  be  correspondingly  great,  and  considerable 
time  be  required  for  complete  recovery ;  indeed,  the 
shock  is  sometimes  so  severe  as  to  occasion  confine- 
ment for  several  days.  Treatment  for  quieting  the 
nervous  system,  consisting  in  agents  of  a  sedative  cha- 
racter, may  be  employed  previously  to  the  operation. 
Stimulants,  as  a  general  rule,  should  be  avoided. 

Where  there  is  a  high  state  of  inflammation  in  the 
immediate  parts,  especially  if  there  is  a  general  in- 
flammatory diathesis,  the  propriety  of  extracting  the 
teeth  is  questionable.  Under  such  circumstances, 
there  is  probably  less  danger  in  the  extraction  of  the 
inferior  teeth  than  of  the  superior.   Where  the  inflam- 


436  EXTRACTION    OF    TEETH. 

mation  has  a  disposition  to  extend,  it  is  liable  to  go 
to  the  head  from  the  superior  maxilla,  and  to  the 
fauces  and  throat  from  the  inferior.  In  cases,  then, 
where  there  is  excessive  inflammation  in  the  imme- 
diate parts,  accompanied  by  a  general  inflammatory 
condition,  both  local  and  general  antiphlogistic  treat- 
ment should  be  adopted. 

Extreme  irritability,  or  a  diseased  condition  of 
parts  having  an  intimate  connection  with  the  teeth, 
as,  the  immediate  surrounding  tissues,  the  salivary 
glands,  and  the  throat,  is  a  circumstance  admonishing 
to  great  caution  in  the  extraction  of  teeth,  especially 
when  such  condition  does  not  depend  on  the  teeth 
for  its  exciting  cause  or  modifying  influence.  It  is, 
however,  very  generally  the  case,  when  any  of  the 
parts  having  an  intimate  relation  with  the  teeth  be- 
come in  any  way  affected,  that  diseased  teeth  will 
exercise  an  injurious  influence  on  them.  If  the  neces- 
sity for  the  removal  of  the  oflending  tooth  is  not  too 
urgent,  the  parts  that  may  be  diseased  about,  it  should 
be  brought  to  as  good  a  condition  as  possible. 

Pregnancy  and  uterine  irritation  frequently  pro- 
duce strong  sympathetic  influences  on  the  teeth,  and 
especially  on  those  which  are  in  an  irritable  condition. 
Even  sound  teeth  may  be  thus  affected,  so  as  to  occa- 
sion great  annoyance.  Such  teeth  are  frequently  pre- 
sented for  extraction ;  but  these  cases  should  always 


CONDITIONS    TO    BE    OBSERVED    IN    EXTRACTION.       437 

be  thoroughly  examined  before  deciding  as  to  the  pro- 
priety of  an  operation.  As  a  consequence  of  this  sym- 
pathetic connection  between  the  teeth  and  the  uterus, 
the  latter,  when  in  an  irritable  condition,  is  very 
liable  to  be  affected  by  any  special  violence  to  the 
former.  In  many  cases,  under  such  circumstances, 
the  extraction  of  a  tooth  is  attended  with  pain  in  the 
uterus ;  and  in  cases  of  pregnancy,  where  there  is  de- 
bility of  the  parts  involved,  abortion  may  follow  the 
operation.  It  is  the  duty  of  the  patient,  under  such 
circumstances,  to  notify  the  operator  of  the  condition, 
or  if  the  latter  has  any  knowledge  of  it,  it  is  his  duty 
to  become  fully  acquainted  with  the  circumstances, 
and  then  to  conform  to  the  indications.  In  such  case, 
treatment  will  avail  but  little  to  prepare  the  system 
for  the  operation.  The  better  method  is  to  adopt 
palliative  treatment,  which,  if  the  affection  is  wholly 
sympathetic,  must  be  directed  to  the  organ  producing 
the  difficulty.  But  if  the  affection  is  in  part  local,  then 
topical  treatment  is  also  indicated.  When  there  is  a 
suppression  of  menstruation,  there  will  be  an  increased 
disposition  to  hemorrhage ;  and  in  the  extraction  of 
the  teeth  of  a  patient  of  hemorrhagic  diathesis,  this 
is  a  point  to  which  attention  should  be  very  specially 
directed.  Here,  of  course,  a  remedy  for  the  obstruc- 
tion would  meet  the  difficulty. 

Persons  subject  to   epilepsy  should  be  very  cau- 


438  EXTRACTION    OF   TEETH. 

tiously  treated  in  all  operations  on  the  teeth,  and 
most  especially  in  their  extraction.  It  is  not  prob- 
able, however,  that  an  operation  of  this  character 
would  increase  the  tendency  to  epilepsy ;  but  any 
undue  excitement  is  liable  to  produce  a  paroxysm  of 
the  disease,  and  hence  the  operator  should  proceed 
to  his  work  with  as  little  parade  as  possible,  yet  not 
stealthily;  the  patient  should  be  thoroughly  aware  of 
what  is  to  be  done;  for,  of  all  patients,  such  a  one  is 
the  last  that  should  be  deceived.  Of  course,  in  a  case 
of  this  kind,  there  can  be  no  prior  treatment  that  will 
avail  anything ;  the  most  that  can  be  done  is,  to  await 
the  fittest  opportunity  in  respect  to  the  paroxysms. 
There  is  no  more  liability  to  fatal  results  with  such 
patients  than  with  others. 


CHAPTER  XII. 

ACCIDENTS   IN    THE    EXTRACTION   OF   TEETH. 

The  accidents  liable  to  occur  to  the  teeth  and  the 
contiguous  parts  in  the  operation  of  extraction  were 
formerly  far  more  frequent  than  at  present.  This 
results  from  the  existence  of  more  perfect  instru- 
ments and  of  more  accurate  and  extensive  knowledge. 
Formerly,  very  few  studied  the  peculiarities  of  the 
teeth,  either  in  their  physical  or  anatomical  struc- 
ture ;  their  peculiar  forms,  as  indicated  by  their 
crowns  ;  their  anatomical  and  physiological  relations 
to  the  contiguous  parts  and  to  one  another ;  and  their 
attachment  as  affected  by  the  character  and  structure 
of  the  tissues  about  them.  The  instruments  em- 
ployed, too,  were,  till  within  a  few  years  past,  very 
crude  in  their  forms,  very  inapplicable  in  that  part 
which  embraces  the  tooth,  inappropriate  in  their 
shapes,  and  defective  in  their  manner  of  applying  the 
force  in  the  operation.  But  these  causes  of  accidents, 
so  far  as  the  better  part  of  the  dental  profession  is 
concerned,  have  been  in  a  very  marked  degree  dimin- 
ished. 


440  ACCIDENTS   IN    THE    EXTRACTION    OF   TEETH. 

Some  of  the  accidents  attendant  or  consequent  on 
the  extraction  of  teeth  are  of  a  grave  character. 
Permanent  deformity  has  sometimes  been  occasioned 
by  extensive  laceration  of  the  soft  parts,  or  by  frac- 
ture of  the  alveolus  and  of  the  maxilla.  Intense  and 
protracted  suffering  frequently,  and  death  sometimes, 
follows  such  accidents. 


HEMORRHAGE. 

Excessive  and  obstinate  hemorrhage  in  some  cases 
follows  the  extraction  of  teeth,  occasionally  resulting 
seriously  and  even  fatally.  There  is  in  some  consti- 
tutions a  hemorrhagic  diathesis,  so  that  from  a  small 
wound,  or  even  a  scratch,  there  will  ensue  persistent 
bleeding.  This  condition  is  dependent,  first,  on  a 
lack  of  tone  in  the  blood-vessels,  so  that  they  fail  to 
contract  at  an  injured  or  ruptured  point ;  and  secondl}'', 
on  a  peculiar  condition  of  the  blood,  such  as  to  pre- 
vent ready  coagulation,  as  when  there  is  a  relative 
deficiency  of  albumin  and  fibrin.  It  is  one  of  the 
most  important  duties  that  ever  devolve  on  the  den- 
tist, to  make  a  correct  diagnosis  in  cases  where  there 
is  a  tendency  to  hemorrhage.  Close  attention  to  the 
following  points  will  assist  much  in  arriving  at  a  just 
conclusion.  In  persons  of  a  hemorrhagic  tendency, 
there  is  a  lymphatic,  serous  temperament ;  a  lack  of 


HEMORKIIAGE.  441 

tone  in  the  soft  parts — a  soft,  flabby  condition ;  the 
skin  pale,  and  devoid  of  the  bright,  vital  appearance; 
the  eyes  and  hair  of  light  color;  and  the  flow  of 
saliva  and  mucus  abundant.  Besides  these  indica- 
tions, much  may  be  learned  sometimes  by  properly 
directed  inquiries  of  the  patient  in  regard  to  a  dispo- 
sition to  hemorrhage  on  being  wounded,  either  in  his 
own  case  or  in  that  of  his  relatives  ;  if  in  the  former, 
under  what  circumstances ;  whether  from  an  exten- 
sive or  slight  wound ;  from  large  or  small  vessels — 
from  arteries  or  veins ;  or  whether  it  occurred  imme- 
diately or  after  the  lapse  of  some  time.  If  the 
patient  has  never  met  with  an  accident  sufficient 
to  occasion  excessive  hemorrhage,  and  any  of  his 
relatives  have,  and  a  tendency  to  bleeding  is  sus- 
pected in  the  case,  the  operator  should  ascertain 
whether  there  is  a  similarity  of  temperament  and 
constitutional  tendencies  between  the  patient  and 
such  relative. 

There  are  certain  conditions  in  which  excessive 
hemorrhage  would  be  more  likely  to  occur  than  in 
others  ;  as,  for  instance,  when  there  is  an  accidental 
relaxati6n,  or  deficient  tone  in  the  system,  especially 
the  vascular;  and  also  when  there  is  a  suppression 
of  any  periodical  discharges.  There  may  be  excess- 
ive hemorrhage  from  a  ruptured  vessel  when  there  is 
no    constitutional  hemorrhagic   tendency.     There  is 


442  ACCIDENTS   IN    THE    EXTRACTION    OF    TEETH. 

sometimes  a  local  difficulty  with  the  vessels — a  lack 
of  tone  in  the  part — or  an  aneurismal  condition — on 
account  of  which  obstinate  hemorrhage  will  occur.  A 
peculiarity  of  this  kind  is  not  very  readily  recognized. 
Violent  passion,  and,  indeed,  any  strong  agitation 
of  the  mind,  will  aggravate  hemorrhage.  Improper 
medication,  as  well  as  highly  stimulating  food,  will 
have  the  same  tendency.  Anything  that  will  in- 
crease the  circulation,  or  reduce  the  tone  of  the 
vessels,  or  change  the  condition  of  the  blood,  will 
increase  the  liability  to  hemorrhage.  Simple  deter- 
mination of  blood  to  a  part,  however,  would  not 
indicate  such  a  liability.  When  there  is  a  special 
hemorrhagic  diathesis,  the  blood  will  flow  from  all 
the  wounded  surface,  will  be  thrown  out  from  all  the 
ruptured  capillaries.  The  most  difficult  cases  are 
those  in  which  there  is  a  defect  both  in  the  vessels 
and  in  the  blood.  If  the  latter  is  in  a  good  condition, 
it  will  coagulate  in  ruptured  capillaries,  though  they 
might  be  deficient  in  tone  ;  but  in  larger  vessels, 
though  coagulum  might  be  formed,  it  would  hardly 
be  retained. 


TREATMENT. 

In  cases  where  there  is  manifest  hemorrhagic  dia- 
thesis, prior  treatment  is  indicated,  if  the  necessity 


HExMORRHAGE — TREATMENT.  443 

of  extraction  is  not  urgent ;  and  that  treatment  will 
be  determined  by  the  peculiar  condition  of  the  case. 
If  there  is  a  lack  of  tone  in  the  vessels — an  inability 
to  contract — then  the  treatment  should  be  of  a  tonic 
character ;  and  if  the  blood  is  in  good  condition,  this 
is  the  only  treatment  necessary ;  but,  if  in  a  vitiated 
state,  other  treatment  will  be  demanded,  the  object 
of  which  is  to  produce  an  increase  of  red  corpuscles, 
albumin  and  fibrin.  It  is  always  better  to  postpone 
an  operation,  if  at  all  practicable,  till  such  treatment 
can  be  had  as  will  bring  the  system  to  the  best  pos- 
sible condition. 

Of  the  several  methods  of  arresting  hemorrhage, 
the  j)roper  one  in  a  given  case  will  be  determined  by 
the  circumstances.  Styptics  or  astringents  applied 
directly  to  the  ruptured  surface  will  often  be  found 
to  produce  coagulation  of  the  blood,  and  thus  stop  its 
flow  without  anything  else.  This  kind  of  remedy 
will  be  efficient  in  those  cases  in  which  the  applica- 
tion will  produce  contraction  of  the  bleeding  vessels, 
as  well  as  coagulation  of  the  blood.  Sometimes  this 
class  of  agents  will  fail  to  accomplish  the  object ;  in 
which  case,  in  addition  to  them,  compression  should 
be  made  upon  the  part.  Indeed,  in  many  cases,  the 
compress  will  effect  all  that  is  desired,  without  any 
other  application. 

There  are  several  methods  of  applying  the  com- 


444  ACCIDENTS    IN    THE    EXTRACTION    OF   TEETH. 

press ;  but  the  one  best  adapted  to  any  given  case 
will  be  determined  by  circumstances — sncb  as  the 
extent  of  the  wound,  the  character  of  the  hemor- 
rhage, the  location  of  the  injury,  and  the  size  of  the 
mouth. 

A  very  common  method  of  making  compression  in 
the  socket  from  which  a  tooth  has  been  drawn,  is  to 
force  into  the  cavity  pledgets  of  cotton,  or  small 
strips  of  linen,  tightly  till  it  is  full.  It  is  well  to 
saturate  these  with  a  solution  of  tannin,  or  some 
astringent  preparation,  applying  it,  too,  in  connection 
with  the  compression.  In  some  cases,  a  simple  pack- 
ing of  the  cavity  in  this  manner  is  quite  sufficient; 
but  in  others  it  is  necessaiy  to  retain  the  pledgets 
in  the  socket  by  means  of  further  compression.  This 
is  effected  by  placing  a  roll  of  linen,  or  perhaps  bet- 
ter, a  properly-formed  piece  of  cork,  on  the  packing, 
and  then  closing  the  jaws  tightly  upon  this,  and,  if 
need  be,  placing  a  bandage  under  the  chin,  and  tying 
it  firmly  over  the  head.  The  length  of  time  during 
which  it  will  be  necessary  to  keep  the  jaws  thus 
together  will,  depending  on  the  nature  of  the  case, 
be  from  one  to  six  hours.  After  the  hemorrhage  has 
entirely  ceased,  the  bandage  is  to  be  removed  care- 
fully, and  the  patient  instructed  to  hold  the  jaws 
together  on  the  compress  for  a  time,  and  then  gradu- 
ally to  open  the  mouth,  and  remove   the  cork  with 


HEMORRHAGE — TREATMENT.  445 

much  caution.  After  this  the  packing  should  re- 
main in  the  socket  from  one  to  three  days,  and  then 
be  removed  very  carefully,  one  piece  at  a  time,  lest 
the  ruptured  vessels  be  opened  and  the  hemorrhage 
caused  to  recur. 

The  object  in  applying  a  compress  is  to  bring  it  to 
bear  upon  the  aperture  of  the  wounded  vessel,  and  in 
this  way  to  prevent  the  escape  of  blood,  till  coagulum 
is  formed  and  the  opening  permanently  closed.  The 
operator  should  ascertain  the  precise  point  from  which 
the  blood  flows,  and  form  the  compress  so  as  to  bear 
full  upon  it.  If  the  flow  is  from  all  the  wounded 
surface,  then  the  compress  must  be  made  to  conform 
exactly  to  that  throughout. 

Another  method  of  making  the  compression,  is  to 
force  softened  wax  into  the  socket,  so  as  to  fit  it  per- 
fectly; remove  it  and  chill  it  in  cold  water;  and  then 
introduce  and  make  compression  upon  it  in  the  man- 
ner already  described,  following  throughout  the 
general  directions.  Another,  and  probably  better, 
method  is  to  form  cones  of  wax  cloth,  as  near  the 
shape  and  size  of  the  root  removed  from  the  socket 
as  possible.  This  material  is  prepared  by  dipping 
thin  linen  into  melted  beeswax,  withdrawing  it  and 
letting  it  cool,  and  then  cutting  off  strips  of  from  a 
fourth  to  half  an  inch  wide,  and  rolling  them  to  the 
proper  size  and  shape ;  having  softened  this  material 


446  ACCIDENTS    IX   THE    EXTRACTION    OF   TEETH. 

by  heat,  and  freed  the  socket  of  coagulum,  introduce 
and  press  it  firmly  into  place,  making  the  compression 
on  it  as  already  directed.  This  makes  a  very  efficient 
compress  for  many  cases. 

Plaster  of  Paris  is  sometimes  used  on  the  principle 
of  a  compress.  Having  the  plaster  mixed  of  the 
proper  consistence,  and  the  cavity  clear,  fill  com- 
pletely with  it,  let  it  set,  and  then  make  compression 
on  it  in  the  usual  manner. 

The  root  of  the  tooth  is  sometimes  returned  to  the 
socket,  to  serve  as  a  compress.  It  possesses  the 
advantage  of  having  a  perfect  adaptation.  This 
method  of  compression  may  be  made  more  thorough 
by  immersing  the  root  in  melted  "svax,  and  then,  before 
this  becomes  too  hard,  introducing  it  into  its  original 
position.  This  makes  a  very  perfect  and  efficient 
compress.  If  the  crown  is  still  remaining,  when  the 
jaws  are  closed  it  will  come  in  contact  with  the  oppos- 
ing teeth,  and  thus  be  kept  firmly  in  place,  without 
anything  further.  It  niny  be  removed  carefully  after 
from  one  to  three  days.  In  cases  where  there  is 
hemorrhage  from  the  entire  wounded  surface,  there 
will  be  a  considerable  flow  of  blood  from  the  margin 
of  the  gum,  even  after  plugging  up  the  socket,  and 
making  compression  by  either  of  the  methods  de- 
scribed. In  such  case,  after  the  socket  is  plugged  up 
as  already  described,  a  plate  is  so  formed  as  to  fit 


HEMORKHAGE — TREATMENT.  447 

tightly  over  the  gum,  and  draw  its  margin  down 
closely  upon  the  compress.  This  pressure  on  the 
bleeding  edges  of  the  gum  checks  the  flow  of  blood 
there.  The  jjlate  must  be  held  down  by  the  means 
already  described.  It  is  sometimes  difficult  to  obtain 
an  accurate  fit  for  the  plate,  so  as  entirely  to  pre- 
vent the  blood  from  continuing  to  ooze  out.  In  such 
cases,  make  the  plate  to  conform  as  nearly  as  con- 
venient to  the  part ;  then  fill  up  its  concavity  with 
plaster  of  Paris,  mixed  to  a  proper  consistence,  and 
then  place  the  whole  upon  the  part,  till  the  plaster 
conforms  exactly  to  it,  and  retain  it  there  till  the 
plaster  sets.  This  is  then  used  for  the  compress. 
Or  the  inside  of  the  plate  may  be  thickly  coated  with 
softened  gutta-percha,  instead  of  plaster,  and  pressed 
upon  the  part  in  the  manner  already  described,  and 
employed  in  the  same  way. 

It  will  often  require  considerable  discrimination  to 
determine  the  best  method  of  obtaining  compression. 
Very  great  difficulty  is  occasionally  experienced  when 
a  portion  of  the  process  has  been  broken  away,  or  the 
soft  parts  have  been  lacerated. 

Various  preparations  are  used  as  hemostatics. 
These  agents  serve  to  check  hemorrhage  in  two 
ways :  first,  by  facilitating  coagulation  of  the  blood ; 
and,  secondly,  by  producing  a  contraction  of  the  ori- 
fice of  the  ruptured  vessels.     It  is  proper  in  all  cases 


448  ACCIDENTS    IN   THE    EXTRACTION    OF   TEETH. 

to  use  styptics  in  connection  with  the  compress.  The 
following  agents  have  been  used  as  styptics  :  tannic 
acid,  creosote,  nitrate  of  silver,  chloride  of  zinc,  sul- 
phate of  zinc,  oil  of  turpentine,  muriate  of  iron.  The 
methods  of  applying  these  different  preparations  are 
the  same.  The  agent  is  simply  to  be  retained  in 
contact  Avith  the  part  till  it  has  exerted  its  influence. 
A  solution  of  tannin  in  alcohol,  with  creosote,  equal 
parts,  makes  a  very  powerful  styptic ;  or  tannin  and 
creosote  alone  is  perhaps  equally  efficient. 

The  actual  cautery  is  sometimes  used  to  arrest 
hemorrhage ;  but  the  propriety  of  using  it  in  cases 
where  there  is  a  manifest  hemorrhagic  diathesis  is 
exceedingly  doubtful.  When  the  cauterized  surface 
is  sloughed  off,  the  hemorrhage  is  liable  to  recur  with 
increased  vigor,  indeed,  is  certain  to  do  so  in  almost 
every  case  where  there  is  a  strong  predisposition. 
Constitutional  treatment  may  be  employed  to  antici- 
pate hemorrhage  ;  and  it  should  have  in  view  an 
increase  of  the  relative  amount  of  red  corpuscles, 
albumen,  and  fibrin  in  the  blood,  and  also  the  produc- 
tion of  a  normal  tone  of  the  system.  Saline  purga- 
tives may  be  used  with  very  decided  advantage, 
followed  with  acetate  of  lead,  in  connection  with 
opium,  the  effect  of  the  lead  being  to  increase  the 
coagulability  of  the  albumen  and  fibrin.  Care  should 
be  exercised,  however,  in  its  administration. 


HEMORRHAGE — TREATMENT.  449 

Excessive  hemorrhage  will  sometimes  occur  from 
very  slight  wounds ;  death  has  been  known  to  ensue 
from  simply  scarifying  the  gums. 

Mr.  C.  desired  the  removal  of  the  first  superior 
molar.  The  gum  was  separated  from  the  neck  of  the 
tooth  with  the  lancet,  in  the  usual  manner,  when  he 
refused  to  have  anything  further  done,  and  left  the 
office,  there  being  a  slight  discharge  of  blood  from 
the  gum.  After  a  few  hours,  the  hemorrhage  in- 
creased, so  as  to  cause  alarm  to  his  friends.  The 
patient  was  about  eight  miles  from  a  dentist,  and  a 
physician  of  rather  moderate  skill  was  called  to  the 
case.  He  probably  acted  according  to  his  best  know- 
ledge, but  foiled  to  arrest  the  hemorrhage,  and  suc- 
ceeded in  convincing  the  friends  that  no  one  else 
could  do  better.  The  flow  of  blood  continued  three 
to  four  days,  proving  well-nigh  fatal,  but  at  last 
abated,  and  the  patient  recovered.  In  this  case,  a 
properly-directed  compress  would  have  checked  the 
bleeding  in  a  few  minutes. 

Another  case  :  Mrs.  T.  had  nine  teeth  removed. 
The  operation  was  not  followed  immediately  by  un- 
usual hemorrhage,  but  within  two  or  three  hours  the 
flow  of  blood  had  increased  to  an  alarming  extent, 
so  as  to  run  from  the  mouth  in  a  continuous  stream. 
The  indications  were  that  the  patient  would  soon  die. 
She  had  become  very  weak.      On  examination,  the 


450  ACCIDENTS    IN   THE    EXTRACTION    OF   TEETH. 

blood  was  found  issuing  only  from  the  socket  of  one 
root  of  an  inferior  molar.  The  mouth  and  socket 
being  cleansed  of  blood  and  coagulum,  it  was  perceived 
that  the  hemorrhage  was  from  a  small  artery  at  the 
bottom  of  the  socket,  spouting  out  in  jets  with  the 
pulsations.  The  treatment  consisted  in  rolling  up 
pledgets  of  cotton  very  tightly,  saturating  them  with 
creosote  and  tannin,  and  forcing  them  in  on  the 
bottom  of  the  socket,  so  as  to  make  compression 
upon  the  bleeding  vessel.  The  socket  was  then  filled 
up,  compression  made,  and  the  head  bandaged  in  the 
manner  already  described.  Thus  the  hemorrhage 
was  immediately  checked,  and  did  not  return.  The 
constitution  of  this  patient  was  of  a  scorbutic  dia- 
thesis. 

Excessive  bleeding  often  does  not  occur  till  a  con- 
siderable time  after  an  operation ;  and  it  may  come 
on  without  any  exciting  cause,  or  be  induced  by 
vigorous  muscular  exercise,  or  by  any  intense  mental 
excitement.  Everything  of  this  kind  should  be 
avoided  where  there  is  a  predisposition  to  hemor- 
rhage, and  everything  invited  that  would  tend  to 
maintain  the  equilibrium  of  the  circulation  and  the 
utmost  quiet. 


FRACTURE  OF  THE  ALVEOLUS.  451 

FRACTURE  OE  THE  ALVEOLUS. 

The  ordinary  fracture  of  the  alveolus  is  a  matter 
of  no  considerable  consequence,  if  it  receives  proper 
attention.  This  fracture  occurs  to  a  greater  or  less 
extent  under  the  following  circumstances  : 

First.  When  there  is  great  divergence  of  the  roots, 
so  that  the  tooth  cannot  pass  from  its  socket,  unless 
one  or  more  of  them  are  broken  off,  or  the  alveolus 
is  fractured. 

Second.  Where  the  tooth  is  forced  out  of  the  socket 
at  a  very  considerable  angle  with  its  axis. 

Third.  Where  the  alveolus  is  very  firmly  attached  to 
the  roots,  and  is  very  thin  toward  the  point  of  these. 

Usually,  the  fracture  is  of  that  part  which  forms 
the  socket  of  the  tooth  removed  ;  and  when  this  is 
the  case,  it  is  of  but  small  moment.  It  sometimes, 
however,  extends  far  beyond  this,  involving  the 
alveolus  of  from  one  to  four  of  the  adjacent  teeth, 
and  causing  very  serious  injury,  even  the  loss  of  the 
teeth  themselves.  Extensive  fracture,  however,  is 
far  less  liable  to  occur  now  than  when  less  perfect 
instruments  were  employed.  When  the  key  was 
in  general  use,  extensive  fracture  of  the  alveolus  was 
frequent ;  but  with  the  forceps,  it  is  comparatively 
rare. 

When  an  accident  of  this  kind  does  occur,  all  of 


452  ACCIDENTS    IN    THE    EXTRACTION    OF   TEETH. 

the  detached  portion,  whether  large  or  small,  should 
be  removed.  A  pair  of  bone  nippers,  or  enucleating 
forceps,  will  answer  for  this  purpose.  If  there  is 
much  attachment  of  the  soft  parts,  it  should  be  dis- 
sected ofP,  and  then  removed.  If  such  fractured  por- 
tions are  permitted  to  remain,  inflammation,  and 
oftentimes  sloughing  of  the  gums,  wall  ensue ;  necrosis 
of  the  bone  is  also  sometimes  produced  by  detached 
bone  remaining  in  contact  with  the  living. 

Sometimes  extensive  fracture  occurs,  involving  the 
adjacent  bony  structure.  In  the  case  of  Mr.  W.,  in 
an  effort  to  remove  the  first  superior  molar,  the  outer 
wall  of  the  alveolus  was  separated  from  the  other 
teeth.  The  fracture  extended  almost  to  the  zygo- 
matic process,  and  detached  a  portion  of  the  floor  of 
the  antrum,  as  well  as  a  part  of  its  outer  wall.  After 
the  removal  of  this  detached  portion,  there  was  a 
considerable  external  depression,  that  very  much 
marred  the  form  and  symmetry  of  the  face. 

Fracture  of  the  alveolus  should  always  be  guarded 
against  as  carefully  as  possible.  It  always  makes  an 
unfavorable  impression  on  the  mind  of  the  patient, 
which  in  many  cases  no  explanation  can  obliterate. 
Whenever  the  accident  does  occur,  the  disagreeable 
knowledge  of  it  may,  if  practicable,  remain  a  secret 
with  the  operator. 


BREAKING    THE    TEETH.  453 

LACERATION    OF    THE    GUMS. 

The  gums  are  often  bruised  and  lacerated  with  the 
key  in  the  extraction  of  teeth.  But  this  accident 
seldom  happens  with  the  forceps;  indeed,  never,  un- 
less the  gum  is  very  firmly  attached  to  the  neck  of 
the  tooth,  and  has  not  been  separated  with  the  lancet. 
The  gum  will  sometimes  be  lacerated  by  adhering 
to  a  piece  of  the  process  while  the  tooth  is  drawn 
from  its  socket,  with  the  process  and  gum  attached. 
With  the  various  hooks  and  punches,  the  gums,  lips, 
and  cheeks  are  sometimes  wounded.  Accidents  of 
this  kind  are  to  be  prevented  by  placing  a  finger  of 
the  left  hand,  or  a  guard  made  of  a  roll  of  linen,  in 
front  of  the  instrument.  When  any  considerable 
portion  of  gum  is  lacerated,  the  detached  portion 
should  be  cut  off.  The  worst  consequences  from 
laceration  of  the  soft  parts  occur  where  there  is  a 
hemorrhagic  diathesis.  The  most  effectual  means 
of  preventing  accidents  of  this  kind  is  to  separate  the 
gum  perfectly,  and  guard  well  the  points  of  the 
instrument. 

BREAKING    THE    TEETH. 

This  is  an  accident  of  no  small  consequence,  and  is 
liable  frequently  to  occur  in  the  use  of  imperfect,  illy- 


454  ACCIDENTS    IN    THE    EXTRACTION    OF   TEETH. 

adapted  instruments,  or  in  the  unskillful  use  of  good 
ones.  It  is  of  very  common  occurrence  when  the  key 
is  employed  for  extracting,  even  in  the  hands  of 
those  who  claim  to  be  skilled  in  its  use.  And  with 
forceps,  too,  of  the  primitive  form,  the  teeth  were  so 
frequently  broken,  as  almost  to  preclude  their  use  as 
extracting  instruments.  This  accident  usually  occa- 
sions great  pain  to  the  patient,  as  well  as  protracts 
the  operation,  and  diminishes  his  confidence  in  the 
ability  of  the  operator.  One  such  accident  will 
create  more  prejudice  than  fifty  skillful  operations 
can  obliterate. 

In  all  cases  where  a  tooth  is  broken,  the  root,  if 
possible,  should  be  removed ;  for  if  it  be  not,  con- 
tinuous or  periodical  pain,  inflammation,  alveolar 
abscess,  and  like  affections,  are  liable  to  ensue.  The 
remark  is  often  made,  when  teeth  are  broken,  that 
the  gums  will  close  over  the  roots,  and  thus  effect- 
ually protect  them,  and  no  disagreeable  consequences 
will  follow.  In  no  ordinary  case  will  the  gums 
unite  over  even  the  smallest  portion  of  root  that 
may  have  been  left  in  the  socket. 

REMOVAL   OF   A    WRONG    TOOTH. 

There  is  very  rarely  any  excuse  for  the  removal  of 
a  sound,  healthy  tooth  in  the  immediate  vicinity  of  a 


KEMOVAL    OF   A    WRONG    TOOTH.  455 

diseased  one,  unless  it  be  in  a  case  of  those  deep- 
seated,  hidden  affections  which  are  difficult  to  diag- 
nose. It  sometimes  happens,  however,  that  a  sound 
tooth  is  removed ;  and  when  a  mistake  of  this  kind 
is  made,  the  diseased  tooth  should  also  be  at  once 
removed,  and  then,  if  the  conditions  are  favorable, 
the  healthy  one  should  be  immediately  replaced. 
The  circumstances  most  favorable  for  such  replace- 
ment are  a  good  constitution  in  a  state  of  health,  and 
a  normal  condition  of  the  mouth,  especially  of  the 
gums  and  mucous  membrane,  so  that  the  attachment 
would  take  place  with  as  little  inflammation  and 
soreness  as  possible.  If  the  tooth  is  necessarily  kept 
out  of  the  mouth  many  minutes,  it  should  be  placed 
in  water  at  about  blood  heat ;  and  before  the  replace- 
ment, the  socket  should  be  thoroughly  cleansed  of 
coagulum.  The  tooth  is  then  introduced,  pressed 
firmly  to  place,  and  allowed  to  remain,  without  dis- 
turbance or  irritation,  till  the  attachment  has  become 
complete.  During  the  time  it  is  reuniting,  treatment 
may  be  required  to  counteract  inflammation.  Meagre 
diet,  abstinence  from  stimulants,  and  quiet,  should 
always  be  recommended  in  the  case. 

This  operation  has  been  wholly  condemned  by  some 
very  good  dentists.  Dr.  Koecker  declares  that  it 
should  never  be  attempted.  But  numerous  success- 
ful cases,  well  attested,  give  assurance  that  it  may 


456  ACCIDENTS    IN   THE    EXTRACTION   OF   TEETH. 

very  frequently  be  accomplished  with  the  most  satis- 
factory results.  Mr.  T.,  aged  fifteen  years,  of  good 
constitution,  and  in  good  health,  and  with  the  mouth 
principally  in  a  normal  condition,  had  the  second 
inferior  bicusj)id  of  the  left  side  removed  by  mistake, 
the  first  molar  being  the  offending  tooth.  The  former 
was  at  once  put  into  cold  water,  and  the  latter  forth- 
with extracted.  The  socket  of  the  bicuspid  was  then 
cleansed,  and  the  tooth  replaced.  There  was  slight 
soreness  for  a  few  days,  after  which  the  tooth  was 
found  to  have  made  a  firm  and  permanent  re-attach- 
ment, and  from  that  time  to  this — thirty-three  years — 
it  has  remained  perfect,  and  is  now  as  healthy,  life- 
like, and  valuable  as  any  other  tooth  in  the  mouth. 

Since  the  issue  of  the  first  edition  of  this  work, 
many  cases  have  come  under  the  observation  of  the 
writer  in  which  detached  teeth  have  been  replaced, 
and  become  as  firmly  fixed  in  the  sockets  as  before  re- 
moval, and  remained  in  apparently  a  healthy  condition 
so  far  as  the  attachment  is  concerned.  In  some  of 
these  cases  very  unfavorable  conditions  were  present. 

So  numerous  and  successful  have  these  cases  been, 
that  the  feasibility  of  replacing  teeth  that  have  been 
improperly  removed  is  a  matter  no  longer  to  be  con- 
troverted, and  especially  when  favorable  conditions 
exist — good  health  and  tone,  both  general  and  local, 
and  the  parts  involved  not  too  much  fractured  or 
lacerated. 


DISLOCATION    OF   THE    INFERIOR    MAXILLA.  457 


DISLOCATION   OF    THE    INFERIOR    MAXILLA. 

The  dislocation  of  the  inferior  maxilla  -is  an  acci- 
dent of  not  very  frequent  occurrence.  In  persons  of 
lax  muscles  and  with  large  mouths,  the  operation  of 
extracting  teeth  is  liable  to  produce  it — sometimes 
when  the  operation  is  on  the  upper  jaw,  but  more 
frequently  when  it  is  on  the  lower.  In  the  former 
case,  it  is  a  result  of  the  patient's  effort  to  open  the 
mouth  ;  but  in  the  latter,  generally  that  of  the  move- 
ment of  the  jaw  by  the  instrument.  The  dislocation 
consists  in  a  downward  and  forward  movement  of 
one  or  both  of  the  condyles,  so  that  they  are  thrown 
out  of  their  sockets,  and  rest  in  front  of  the  anterior 
rim.  In  such  case,  the  mouth  is  distended  to  its 
utmost,  the  chin  thrown  down  on  the  breast,  and 
deglutition  and  speech  rendered  impossible.  Some- 
times but  one  condyle  will  be  thrown  out,  in  which 
case  the  jaw  is  thrown  downward  and  to  one  side. 

This  accident  seldom  or  never  occurs  with  patients 
who  have  small  mouths  or  firm  muscles.  When  it 
does  happen,  however,  the  dislocation  should  be 
promptly  reduced.  Of  the  various  methods  of  accom- 
plishing this  reduction,  the  one  most  commonly  em- 
ployed, which  is  very  efficient,  is  as  follows :  If  both 
condyles  are  dislocated,  place  corks  or  some  similar 


458  ACCIDENTS    IN    THE    EXTRACTION    OF    TEETH. 

substance  between  the  superior  and  the  inferior  mokr 
teeth  of  both  sides,  and  then,  with  the  fingers  of 
both  hands,  make  firm,  steady  pressure  on  the  chin 
upward  and  backward,  thus  forcing  the  condyles 
downward  and  backward  into  their  proper  places. 
If  but  one  condyle  is  out,  the  cork  should  be 
applied  only  on  that  side,  and  in  the  manner  already 
directed.  Another  method  is,  to  substitute  the 
thumbs  of  the  operator  for  the  corks,  placing  them 
in  the  same  position  between  the  teeth,  and  manipu- 
lating with  the  fingers  on  the  chin,  as  before.  The 
patient  should  be  placed  in  a  recumbent  position  for 
the  operation.  Another  method  is,  to  make  down- 
ward and  backward  pressure  on  the  coronoid  process, 
and  in  this  manner  cause  the  condyles  to  glide  into 
their  places.  This  accomplishes  the  reduction  with- 
out taking  hold  of  the  jaws,  or  placing  a  fulcrum 
between  them. 

This  accident  is  far  more  liable  to  occur  the  second 
time  in  the  same  case.  In  extracting  the  lower  molar 
teeth  for  a  person  who  has  suffered  a  dislocation,  or 
is  predisposed  to  it,  the  lower  jaw  should  be  very 
firmly  supported  with  the  left  hand  ;  or  the  accident 
may  be  prevented  by  placing  a  bandage  under  the 
chin  and  over  the  head,  so  that  the  mouth  cannot  be 
opened  to  its  furthest  extent ;  and  this  is  the  surest 
method.     In  all  cases  after  an  accident  of  this  kind. 


SYNCOPE.  459 

the  patient  should  abstain  from  solid  food  for  a  few 
days,  or  at  least  till  the  soreness  is  abated,  and  avoid 
everything  promotive  of  inflammation. 


SYNCOPE. 

Syncope,  or  fainting,  is  frequently  brought  on  by 
extraction  of  the  teeth,  and  even  by  other  operations 
upon  them ;  indeed,  it  is  sometimes  produced  simply 
by  cutting  the  gums,  or  by  the  sight  of  blood,  or,  in 
some  instances,  by  dread  of  an  operation.  It  con- 
sists in  an  intermission  of  the  heart's  action,  and 
consequent  irregularity  of  the  circulation,  accom- 
panied with  a  temporary  suspension  of  the  functions 
of  the  brain,  and  a  loss  of  consciousness.  Difficult 
or  suspended  respiration,  pallor  of  the  skin,  and 
inability  to  move,  are  the  external  indications  of  the 
condition.  There  are  no  constitutional  appearances 
known  by  which  a  predisposition  to  syncope  can  be 
determined.  Persons  of  all  apparent  conditions  and 
peculiarities  are  subject  to  it.  The  most  strong, 
robust,  and  healthy  sometimes  faint  under  the  most 
trivial  influences,  while  others,  of  the  weakest  and 
feeblest  constitutions,  cannot  be  brought  into  this  con- 
dition by  any  ordinary  means ;  so  that  nothing  can  be 
predicated  of  appearances  as  to  such  predisposition. 
The  fainting  may  occur  once  or  twice  in  the  same 
case,  even  under  the  most  simple  operation,  owing  to 


460  ACCIDENTS    IN    THE    EXTRACTION    OF   TEETH. 

some  temporary  condition  of  the  system,  and  never 
happen  again  under  any  circumstances  whatever. 

It  sometimes  comes  on  before,  sometimes  after,  and 
sometimes  during,  the  operation.  There  is  greater 
liability  to  it  after  a  recent  meal  than  after  digestion 
is  completed,  since  the  nervous  energy  during  diges- 
tion is  directed  to  the  stomach  and  its  appendages, 
and  thus  the  circulatory  apparatus  has  less  of  nervous 
force. 

The  frequent  occurrence  of  syncope  indicates  a 
constitutional  predisposition  to  it,  and  may  enable  the 
operator  to  anticipate  it  to  some  extent,  by  the  aid 
of  stimulants,  such  as  brandy,  or,  what  is  in  some 
respects  preferable,  a  galvanic  current.  The  patient 
subject  to  such  affection  should  be  placed,  for  an 
operation,  as  nearly  as  practicable  in  a  recumbent 
position, — especially  for  the  extraction  of  teeth, — 
and  his  mind  kept  as  tranquil  as  possible. 

To  restore  the  patient  from  syncope,  place  him  in 
a  horizontal  position,  the  head  quite  as  low  as  the 
body,  and  apply  volatile  stimulants  to  the  nostrils, 
and  dash  water  on  the  face  and  chest.  All  compres- 
sion should  be  removed  from  the  body,  especially 
from  the  chest,  as  it  would  constrain  the  action  of 
the  respiratory  muscles.  This  remark  is  peculiarly 
applicable  to  female  patients.  This  treatment  will 
usually  be  quite  sufficient  to  effect  a  rapid  reaction 
and  resuscitation. 


CHAPTER  XIII. 

ANESTHETICS. 
ETHER CHLOROFORM NITROUS   OXIDE. 

Sulphuric  ether  was  the  first  agent  successfully 
employed  for  producing  insensibility  to  pain  during 
surgical  operations.  It  was  brought  to  the  notice  of 
the  profession  in  1846,  by  the  late  Dr.  Horace  Wells, 
of  Hartford,  Conn. 

The  mode  of  administering  it  is  by  inhalation  of 
the  vapor ;  and  it  produces  its  effects  in  a  short  time, 
depending  on  the  quality  of  the  ether,  the  amount  of 
air  introduced  with  it,  and  the  susceptibility  of  the 
patient.  A  complicated  instrument,  denominated  an 
inhaler,  was  first  employed  for  its  administration ; 
but  it  soon  became  apparent  that  this  was  not  at  all 
necessary,  and  that  simpler  methods  were  preferable, 
because  more  easily  regulated  and  adapted  to  vary- 
ing circumstances.  The  best  method  is  to  inhale  it 
from  a  sponge  or  napkin,  since  in  this  way  the 
admission  of  the  air  can  be  controlled  entirely  by  the 
will  of  the  operator,  graduating  it  to  the  require- 
ments of  the  case. 


4G2  ANESTHETICS. 

During  the  administration,  the  patient  shouhl  be 
in  a  reclining  posture  ;  though  it  is  held,  by  good 
authority,  that  a  horizontal  position  is  the  safest, 
because  in  that  the  force  of  the  circulation  is  most 
nearly  equalized.  In  the  administration  of  general 
anaesthetics,  the  circulation  is  always  more  or  less 
affected.  It  is  an  opinion  very  generally  received, 
and  probably  correct,  that  where  there  is  functional 
derangement  of  the  heart,  lungs,  or  brain,  general 
anaesthesia  should  not  be  employed.  This  opinion, 
however,  is  perhaps  derived  more  from  analogy  than 
from  actual  observation.  It  is  true  that,  other  things 
being  equal,  the  liability  to  injury  in  such  case  would 
be  greater ;  but  the  danger  with  both  ether  and  chlo- 
roform is,  that  there  are  cases  in  which  there  is  an 
undefinable  and  undetectable  idiosyncrasy,  or  mal- 
susceptibility  of  its  influence,  to  a  great  extent  inde- 
pendent of  pathological  conditions. 

The  patient  having  been  placed  in  a  comfortable 
position,  and  his  mind  freed  as  far  as  possible  from 
apprehension,  he  should  be  directed  to  breathe  tran- 
quilly by  full  inspirations,  carefully  guarding  against 
any  compression  of  the  chest,  so  as  to  allow  the  re- 
spiratory muscles  free  play.  During  the  administra- 
tion of  the  anaesthetic,  a  strict  watch  must  be  main- 
tained over  the  patient,  having  reference  to  the  fol- 
lowing points :    The  breathing   should    be   free  and 


ETHER — CHLOROFORM.  463- 

easy,  without  irritation  of  the  throat  or  bronchia ;  the 
skin  shonkl  not  become  blanched,  but  should  retain 
a  florid,  lively  color ;  but  the  great  criterion  is  the 
pulse,  and  the  indications  given  here  should  be 
strictly  observed  and  obeyed.  In  order  that  the 
operator  may  follow  every  indication,  he  should  be 
familiar  with  the  manifestations  of  the  pulse  in  diffe- 
rent constitutions  and  under  different  circumstances. 
During  the  administration  of  ether  or  chloroform,  the 
pulse  usually  becomes  more  frequent;  but  it  should 
not  be  much  accelerated,  nor  its  strength  and  fullness 
be  much  diminished.  Enfeebled  or  irregular  pulse 
should  in  all  cases  be  regarded  as  a  warning;  and  if 
the  feebleness  and  irregularity  be  very  marked,  the 
operator  should  desist.  In  some  instances  death 
has  occurred  after  a  few  inhalations  ;  but  perhaps 
only  in  the  use  of  chloroform.  This  fact  indicates 
that  the  first  effects  of  the  administration  should  be 
very  closely  noted. 

The  degree  to  which  the  ansesthesia  should  be  car- 
ried is  a  matter  about  which  there  is  much  diversity 
of  opinion.  Every  condition  of  it,  from  that  of  simple 
allayed  ii-ritability  to  that  of  complete  insensibility 
and  unconsciousness,  has  its  advocates.  But  the 
extent  to  which  the  administration  may  be  carried 
will  be  suggested  by  the  indications  already  referred 
to,  and,  if  these  are  unfavorable,   should  be  deter- 


464  ANESTHETICS. 

mined  at  once.  Mere  nausea,  however,  without  any 
other  unfavorable  symptom,  is  not  a  counter-indica- 
tion in  the  use  of  ether  or  chloroform. 

The  method  of  administering  chloroform  is  the 
same  as  that  for  ether,  except  that  in  the  use  of  the 
former  more  care  and  closer  observation  are  required. 
Chloroform  is  more  rapid  and  powerful  in  its  action 
than  ether,  and  hence  more  liable  to  do  injury ;  but, 
independently  of  this  fact,  it  is  generally  believed 
that  the  former  is  less  safe  than  the  latter,  when 
taken  into  the  system,  especially  by  inhalation.  A 
mixture  of  ether  and  chloroform,  or  chloric  ether — 
usually  equal  parts  of  chloroform  and  ether,  but  the 
proportions  are  sometimes  varied — is  used  by  some, 
the  object  being  to  secure  greater  promptness  than 
with  ether  alone,  and  incur  less  danger  than  with 
chloroform  ;  and  it  is  probable  that  a  mutual  compen- 
sation in  these  respects  is  thus  to  be  attained. 

If  either  chloroform  or  ether  has  been  administered 
to  entire  unconsciousness,  the  patient  should  be  per- 
mitted to  pass  out  of  the  condition  spontaneously; 
for  after  such  a  revival  there  will  be  less  liability  to 
unpleasant  feelings,  as  headache,  depression,  and 
nausea.  The  fingers  of  the  person  administering  the 
chloroform  should  be  kept  on  the  carotid,  since  the 
state  of  the  circulation  will  be  better  recognized  by 
this  than  by  the  radial  artery,  and  it  is  a  more  con- 


ETHER — CHLOROFORM.  465 

venient  point  for  observation.  In  favorable  cases,  it 
is  preferable  to  continue  the  inhalation  till  there  is 
muscular  relaxation. 

When  a  condition  arises  in  which  respiration  is 
suspended,  and  the  circulation  partially  or  altogether 
stopped — a  condition  of  imminent  peril — active  mea- 
sures must  be  resorted  to  for  the  patient's  restoration. 
Efforts  must  be  directed  to  a  recovery  of  the  circula- 
tion, by  friction,  motion,  etc. ;  but  to  restore  the 
respiration,  is  the  first,  immediate,  imperative  con- 
sideration. Any  or  all  qf  the  ordinary  methods  of 
re-establishing  suspended  respiration  may  be  em- 
ployed. Cold  water  should  be  dashed  in  the  face, 
and  on  the  throat  and  chest,  and  volatile  stimulants 
applied  to  the  nostrils  ;  the  glottis  should  be  titillated 
with  a  feather,  or  some  such  implement,  to  excite  it 
to  action  ;  and  artificial  respiration,  by  some  approved 
method,  should  be  at  once  adopted.  The  galvanic 
current,  too,  may  be  brought  into  requisition,  to 
excite  the  respiratory  muscles  to  action,  and  to  act 
also  upon  the  circulation.  In  all  cases  of  accident  of 
this  kind,  prompt  and  efficient  measures  should  be 
immediately  taken,  for  a  delay  of  a  few  moments 
may  be  attended  with  fatal  results. 


466  •  ANESTHETICS. 

NITROUS    OXIDE. 

Nitrous  oxide  is  now  used  as  a  general  anaesthetic 
quite  extensively  in  dental  practice.  This  agent, 
when  properly  prepared,  and  judiciously  administered, 
is  perhaps  the  safest  general  anaesthetic  in  use;  it  is 
very  efficient  for  minor  surgical  operations,  and  we  be- 
lieve it  will  ere  long  be  found  applicable  to  the  more 
protracted  and  graver  operations.  Its  efficiency  is 
very  much  modified  by  its  preparation  and  mode  of 
administration.  This  gas  when  pure  is  colorless,  and 
of  slightly  sweetish  taste  and  odor ;  it  is  usually  pre- 
pared by  decomposition  of  nitrate  of  ammonia. 

It  is  not  the  purpose  here  to  describe  the  method 
of  preparing  this  agent — that  has  been  well  done  by 
others ;  yet  it  is  proper  to  suggest  here  that,  to  a 
large  extent,  the  knowledge  and  opinions  entertained 
on  this  subject  have  been  very  circumscribed,  and 
exceedingly  erroneous.  In  the  administration  of 
nitrous  oxide  as  an  anaesthetic,  great  care  should  be 
exercised  to  secure  the  best  results.  In  order  to 
accomplish  this,  it  should  be  inhaled,  and  in  no  case 
but  once,  diluted,  as  circumstances  may  indicate,  more 
or  less  with  pure  atmospheric  air ;  this  is  ordinarily 
necessary  only  at  the  beginning,  for  pure  nitrous 
oxide  will  sustain  respiration  for  an  indefinite  time- 
To  a  patient  in  an  anaesthetic  state,  it  is  not  so 


NITROUS    OXIDE.  •  467 

readily  administered  as  chloroform  or  ether;  but  the 
patient  under  its  influence  is  quite  as  manageable  as 
with  any  other  agent,  and  the  ansesthesia  as  perfect, 
but  not  as  prolonged  without  continued  administration. 

It  is  scarcely  justifiable  in  ordinary  dental  practice 
to  use  a  more  heroic  general  anaesthetic  than  the  one 
here  referred  to. 

Nitrous  oxide  gas  is  now  prepared  in  liquid  form, 
and  may  be  procured  of  the  manufacturers,  ready  for 
use.  There  are  some  advantages  derivable  from 
this.  The  gas  in  this  form  is  prepared  by  persons  of 
extended  knowledge  and  experience  in  chemical 
work,  which  gives  assurance  of  purity ;  and,  in  addi- 
tion to  this,  by  the  condensation  to  the  liquid  form, 
any  extraneous  gases  are  expelled,  and  thus  there  is 
f;ir  greater  certainty  of  obtaining  pure  gas  than  when 
it  is  prepared  in  the  ordinary  way,  and  that  by  per- 
sons having  little  or  no  knowledge  of  chemical  science 
or  processes. 

The  accompanying  cut  represents  an  ornamental, 
convenient  and  efficient  gas  holder.  The  liquid  gas 
is  contained  in  the  cylinder  in  the  lower  part ;  from 
this  the  gas  escapes  into  the  holder  above,  directly 
from  which  the  gas  is  administered  to  the  patient. 
A  portable  apparatus  for  holding  and  administering 
the  gas  is  also  constructed,'  which  for  some  purposes 
is  preferable  to  this. 


468 


ANiESTHETICS. 
Fiff.  123. 


LOCAL    ANAESTHESIA. 


Because  of  the  frequently  prejudicial  and  sometimes 
fatal  consequences  to  which  systemic  anaesthesia  is 


LOCAL    ANESTHESIA. 


469 


liable,  local  anaesthesia  has  been  brought  into  requi- 
sition ;  the  first  method  of  accomplishing  this  was  by 

Congelation. — Freezing  a  part,  to  produce  insensi- 
bility under  surgical  operations,  is  a  process  that  has 
long  been  in  use.  Various  methods  for  accomplishing 
it  have  been  employed.  There  are  perhaps  none  so 
well  adapted  to  the  artist's  use  as  ether  spray.  So 
easy  of  application  is  it,  and  so  generally  efficient, 
that  it  is  in  almost  universal  use.  To  Dr.  Richard- 
son, of  London,  is  due  the  credit  of  having  brought 
this  process  to  its  present  state  of  perfection. 

So  accurately  does  the  accompanying  engraving 
(Fig.  124)  represent  the  apparatus  used  in  this  pro- 
Fig.  124. 


cess,  that  a  minute  description  is  unnecessary.  The 
mode  of  application  and  operation  is  apparent  at 
once. 

The  instrument   consists  of  the   fluid   holder — a 
four-ounce  bottle,  graduated — the  bellows  consisting 


470  ANESTHETICS. 

of  a  rubber  ball,  with  the  proper  valves,  and  the 
points  from  which  proceed  the  spray,  and  these  all 
connected  by  the  proper-sized  flexible  tube. 

It  will  be  observed  that  there  are  variously-formed 
points,  single  and  double,  straight  and  curved ;  these 
are  required  for  the  various  processes  to  which  the 
instrument  is  applied. 

For  the  extraction  of  teeth,  the  double  point  is 
applicable,  throwing  a  jet  upon  the  gum  each  side 
of  the  tooth  at  the  same  time.  The  single  points 
are  required  where  an  incision  or  excision  is  to  be 
made. 

This  is  a  very  valuable  instrument,  and  is  exten- 
sively used  in  minor  surgical  operations,  and  is  espe- 
ciaDy  adapted  to  the  dentist's  use.  Ether  is  perhaps 
as  yet  the  best  agent  employed.  Rhigolene,  a  far 
more  volatile  fluid  than  ether,  has  been  used  to  a 
limited  extent,  but  owing  to  its  exceedingly  rapid 
evaporation,  its  action  is  too  violent,  and  not  so 
easily  controlled. 

For  inducing  local  anaesthesia,  various  prepara- 
tions have  been  suggested.  The  following  has  been 
in  use  for  several  years,  namely,  a  mixture  of  chloro- 
form, tincture  of  aconite,  belladonna,  and  opium. 

This  applied  to  the  gums,  or,  indeed,  to  any  other 
surface  tissue,  will  in  many  cases  very  much  obtund 
sensibility,  and  in  some  relieve  it  altogether,  so  that 


LOCAL    ANESTHESIA.  471 

a  tooth  may  be  extracted,  or  a  deep  incision  made, 
without  pain. 

The  dental  pain  obtunder  which  was  introduced  to 
the  profession  about  three  years  ago,  for  relieving 
sensitive  dentine,  is  a  good  local  ansesthetic.  Another 
preparation,  made  and  introduced  by  Dr.  C.  Von 
Bonhorst,  is  also  quite  efficient. 

Dr.  Von  B.  has  invented  an  instrument  for  using 
his  preparation,  or  any  other  for  like  purpose.  It 
consists  of  two  small  metallic  cups,  attached  to  the 
ends  of  an  elongated  staple,  of  heavy  wire,  about 
seven  inches  long.  This  is  the  handle  of  the  appli- 
ance. 

The  sponges  are  placed  in  sections  of  ru\)ber  tube, 
about  half  an  inch  in  length,  and  these  together  are 
placed  in  the  cups.  The  sponges  are  saturated  with 
the  anaesthetic  fluid  that  may  be  selected,  and  are 
applied  to  the  gum  on  each  side  of  the  tooth  to  be 
extracted,  and  retained  on  the  part  from  one  half  to 
two  minutes ;  the  length  of  time  will  be  governed  by 
the  susceptibility  of  the  part,  the  agent  employed, 
and  the  extent  of  the  ansethesia  sought. 

Entire  insensibility  to  pain  cannot  thus  always  be 
obtained,  but  in  many  cases  it  can,  and  diminution 
of  it  in  all  cases  can  be  effected.  This  appliance 
is  very  convenient  for  the  purpose  for  which  it  is 
used. 


472 


ANAESTHETICS. 


The  following  cut  (Fig.  125)  represents  the  instru- 
ment ready  for  use. 

(Fig.  125.) 


f^ 


EXTRACTION    BY    ELECTRO-MAGNETISM. 

The  employment  of  electro-magnetism  in  the  ex- 
traction of  teeth  was  introduced  to  the  profession 
about  fifteen  years  ago,  and  at  one  time  was  exten- 
sively used.  There  is  a  great  diversity  of  opinion  as 
to  its  efficiency  for  relieving  pain ;  for,  while  some 
have  been  disposed  to  assume  that,  when  properly 
employed,  it  w^ould  in  the  majority  of  cases  mitigate 
pain,  and  in  many  obviate  it  altogether,  others,  after 
having  thoroughly  tested  it,  as  they  affirm,  maintain 
that  it  does  not  produce  insensibility  to  any  appreci- 
able extent,  and  consequently  does  not  relieve  the 
pain,  but  that,  at  most,  it  only  complicates  the  sensa- 
tions, the  pain  of  the  tooth-drawing  becoming  in- 
volved in  the  confusion  of  other  feelings,  so  that  the 
patient  can  hardly  decide  whether  he  has  been  defi- 
nitely hurt  oi"  not. 

In  using  this  agent  for  the  purpose  of  extracting 
teeth,  the  susceptibility  of  the  patient  to  its  influence 


APPLICATION.  473 

must  be  carefully  regarded.  Some  persons  are  so 
peculiarly  constituted  that  an  electric  current  is 
almost  intolerable  to  them,  while  others  will  receive 
a  strong  current  with  pleasurable  sensations.  To  the 
former,  the  electricity  would  be  as  painful  as  the  ex- 
traction of  the  tooth ;  but  to  the  latter,  when  properly 
applied,  it  mitigates,  and  in  many  cases  altogether 
obviates,  the  pain.  The  reason  of  this  difference  in  its 
action  is  not  very  clearly  understood.  Several  theories 
in  regard  to  it  have  been  advanced,  but  none  of  them 
sufficiently  plausible  to  challenge  conviction. 

Again,  the  manner  in  which,  and  the  condition  of 
the  parts  to  which,  this  agency  is  applied,  are  to  be 
closely  observed.  Where  there  is  acute  periostitis,  an 
electric  current,  even  though  feeble,  would  produce  in- 
tense pain,  and  should  not  be  applied ;  though  in  such 
cases  it  has  been  suggested  that  an  application  of  the 
charged  sponge  to  the  gums  will  produce  insensibility. 

APPLICATION. 

The  method  of  application  is  very  simple.  Any 
ordinary  battery,  of  convenient  form,  may  be  em- 
ployed for  this  purpose.  It  should  be  uniform  in  its 
action,  and  the  vibration  as  short  as  possible.  The 
common  zinc-and-copper  battery,  with  the  sulphate- 
of-iron  solution,  is  perhaps  the  most  convenient  and 


474  •    ANESTHETICS. 

safe.  One  pole  of  the  battery — no  matter  which — is 
attached  to  the  forceps,  and  the  other  to  a  handle  of 
size  and  form  convenient  for  the  patient  to  grasp.  To 
ascertain  his  susceptibility,  the  current  should  always 
first  be  tested  on  the  patient,  by  placing  the  handle 
and  the  forceps  one  in  each  of  his  hands,  and  letting 
it  on  first  feebly,  and  then  gradually  increasing  it  till 
he  experiences  the  sensation  just  beyond  the  elbows  ; 
when,  finally,  it  is  to  be  slightly  weakened.  The 
gum  having  been  separated,  the  forceps,  with  its 
appendages,  is  adjusted  to  the  tooth,  the  connection 
made  by  placing  the  handle  in  the  patient's  hand,  and 
the  tooth  at  that  moment  removed.  It  has  been  re- 
commended by  some  to  place  the  forceps  on  the  tooth, 
and  complete  the  circuit  as  above,  with  the  current 
very  feeble,  and  then  gradually  increase  it  to  the 
proper  force  for  the  operation.  In  some  instances, 
perhaps,  this  would  be  the  preferable  mode. 

Another  method  of  producing  insensibility  by  an 
electric  current  is,  to  place  two  moistened  sponges, 
connected  with  the  two  poles  of  the  battery,  on  the 
gum,  one  on  each  side  of  the  tooth,  keep  them  there 
a  few  moments,  and  then  operate.  This  method, 
however,  has  not  yet  been  sufficiently  tested  to 
ascertain  its  merits. 


APPENDIX. 


In  the  following  pages  are  presented  a  few  subjects,  more  at 
length  than  is  practicable  or  desirable  in  the  body  of  the  work. 

Section  A.  consists  of  selections  from  "  Watt's  Chemical 
Essays"  on  "  Caries  of  the  Teeth." 

This  is  perhaps  the  most  accurate  and  concise  presentation  of  that 
subject  in  the  English  language.  In  treating  of  the  subject,  it 
deals  with  established  principles  and  with  facts,  and  discards  all 
mere  hypothesis,  which  has  commonly  entered  so  largely  into  the 
discussion  of  the  subject.  A  careful  and  thorough  study  of  the 
subject,  as  here  presented,  is  suggested.  T. 

SECTION  A.— DENTAL  CARIES. 

It  is  now  admitted,  by  all  who  are  familiar  with  the  subject, 
that,  whatever  may  be  the  predisposing  causes,  the  immediate  cause 
of  dental  caries  is  chemical  action.  It  is  well  known  that  consti- 
tutional causes  have  much  to  do  with  this  disease,  both  in  pro- 
ducing badly-organized,  defective  teeth,  and  in  eliminating  or  pre- 
paring the  agents  which  act  chemically  on  them.  But  no  consti- 
tution produces  teeth  so  defective  that  they  undergo  spontaneous 
decomposition  while  retaining  a  vital  connection  with  the  general 
system,  I  am  aware  that  a  few  pathologists  still  maintain  that 
inflammation  of  the  bony  texture  of  the  teeth  is  liable  to  the  same 
terminations  as  inflammation  of  ordinary  bony  tissue ;  but  it  is  not 
profitable  to  debate  this  point  in  the  present  paper.  Sufl&ce  it  to 
say  that  the  structure  and  position  of  the  enamel  indicate  that  the 
danger  is  from  without,  not  from  within. 


476  APPENDIX. 

As  soon  as  it  is  aduiittcd  that  decay  of  the  teeth  results  from 
chemical  action,  it  is  natural  to  inquire  what  agent  or  agents  pro- 
duce this  action.  Accordiugly  we  find  the  profession  turned  at 
once  in  this  direction.  And  when  the  composition  of  the  teeth  is 
taken  into  the  account,  we  would  infer  that  the  deleterious  agents 
are  to  be  looked  for  among  the  acids.  And  here  we  have  had 
great  confusion  of  ideas,  and  are  still  likely  to  have  it.  For 
example,  we  are  told  "  that  it  is  proven  that  nearly  all  the  acids, 
both  mineral  and  vegetable,  act  readily  upon  the  teeth."  {Harris 
Dictionary^  article  "  Caries  of  the  Teeth.")  Upon  any  part  of  the 
teeth  ?  Or  are  we  to  understand  that  some  of  them  act  on  the 
animal  portion,  some  on  the  earthy,  and  some,  or  all,  on  the  enamel  ? 
Just  turn  to  the  index  of  almost  any  chemical  text-book,  and  ask 
yourself  if  it  is  proved  that  nearly  all  of  the  acids  there  named  act 
readily  upon  the  teeth.  Do  carbonic  acid,  tannic  acid,  and  scores 
of  others  that  might  be  named,  act  readily  upon  the  teeth  ?  This 
expression,  and  many  others  that  might  be  quoted  from  various 
writers,  show  a  professional  longing  for,  rather  than  an  attainment 
of,  the  truth  in  regard  to  this  matter. 

I>ow,  for  convenience,  let  us  assume  that  dental  caries  is  pro- 
duced by  the  action  of  acids.  The  question  still  arises,  what  acids? 
Are  many  acids,  or  only  a  few,  concerned  in  its  production  ?  One 
of  the  laws  of  combination  teaches  us  that  chemical  compounds  are 
definite  in  their  nature.  Chemical  action  is  always  definite.  When 
an  acid  combines  with  an  alkali,  or  base,  a  definite  compound, 
called  a  salt,  is  formed.  When  a  difierent  acid  unites  with  this 
same  base,  a  different  salt  is  formed.  Each  salt,  each  chemical 
compound  of  any  kind,  is  distinguished  from  all  others  by  char- 
acteristics peculiar  to  itself  It  is  unlike  all  other  substances,  in 
some  respects.  Each  chemical  result  differs  from  all  other  chemi- 
cal results.  Of  course,  then,  a  great  variety  of  chemical  reagents 
will  produce  a  great  variety  of  chemical  reactions. 

Let  us  now  inquire  as  to  the  various  characteristics  of  those 
chemical  actions  which  result  in  what  we  recognize  as  dental  caries. 
Do  we  here  find  a  great  variety  of  appearances  ?  Or  is  it  not  well 
known  that  the  phenomena  of  caries  are  so  few,  and  so  circum- 
scribed, that  by  common  professional  consent,  but  three  or  four  vari- 


DENTAL   CARIES.  477 

eties  of  it  are  recognized  ?  We  fiad  one  variety  often  called  "  white 
decay,"  and  another  that  is  brownish  in  color,  and  a  third  that  is 
very  properly  designated  as  "  black  decay."  These  differ  in  other 
respects  as  well  as  in  color.  In  the  white  variety  all  the  com- 
ponents of  the  teeth  are  acted  on,  and  disintegrated,  as  far  as  the 
disease  extends.  In  the  second  variety,  the  earthy  portion  of  the 
teeth  seems  to  be  removed,  while  much  or  all  of  the  animal  portion 
remains,  which  is  conclusive  evidence  that  the  chemical  a<rent, 
whatever  it  may  be,  forms  soluble  compounds  with  the  earthy 
materials.  In  the  "  black  decay"  there  is  less  disintegration  of  the 
tooth  substance  than  in  either  of  the  other  varieties ;  and  it  pro- 
gresses less  rapidly  than  either  of  them.  The  physical  character- 
istics of  this  variety,  aside  from  the  chemical,  would  indicate  that 
the  chemical  agent  principally  concerned  in  its  production  forms, 
mainly,  insoluble  compounds  with  the  constituents  of  the  tooth. 
Then,  there  is  a  fourth  variety,  commonly  called  •'  chemical  abra- 
sion," in  which  the  entire  tooth-substance  is  removed,  as  far  as  the 
disease  extends.  It  is  evident  that  the  agent  producing  this,  dis- 
solves or  forms  soluble  compounds  with  both  the  animal  and  earthy 
materials  of  the  tooth. 

Unless  we  conclude  that  chemical  compounds  are  not  definite  in 
their  nature,  and  that  many  reagents  may  produce  but  a  few  reac- 
tions, we  are  forced  to  the  conclusion  that  dental  caries,  as  observed 
and  recognized,  results  from  the  action  of  but  few  substances  on 
the  teeth.  It  is  very  probable  that  each  distinct  variety  is  pro- 
duced by  the  action  of  a  single  agent,  and  invariably  by  the  same 
agent.  I  am  well  aware  that  more  than  one  variety  may  be  found 
in  the  same  mouth  at  the  same  time,  and  in  close  proximity;  and, 
consequently,  any  given  case  of  caries  may  partake  of  the  charac- 
teristics of  more  than  one  variety.  It  is  not  uncommon  to  find 
"  white  decay"  attacking  a  tooth  in  a  cavity  primarily  affected  with 
the  brown,  or  colorless  variety.  But  every  practitioner  is  familiar 
with  unmixed  cases,  representing  all  the  four  classes  specified. 

The  physical  characteristics  of  decay  depend  much  on  the  tex- 
ture of  the  teeth  affected ;  but  they  are  dependent,  also,  on  the 
nature  of  the  compounds  formed  by  the  union  of  the  destroying 
agrent  with  the  constituents  of  the  teeth.     The  degree  of  concen- 


478  APPENDIX. 

tration  of  the  chemical  agent  has  also  a  modifying  influence. 
When  much  diluted,  its  action  is  almost  solely  in  obedience  to  its 
strongest  affinity.  For  example,  if  nitric  acid  were  the  agent,  when 
concentrated  it  would  act  energetically  on  the  animal  as  well  as  on 
the  earthy  materials  of  the  teeth  ;  but  when  much  diluted,  its  action 
would  be  almost  confined  to  the  latter. 

The  chemical  characteristics  of  decay,  however,  depend  almost 
exclusively  on  the  character  of  the  agent  producing  it.  The  truth 
of  this  appears  evident  when  we  reflect  that  bad  teeth  and  good 
ones  are  composed  of  the  same  chemical  substances.  Marble  and 
chalk  are  alike  in  chemical  composition,  but  not  in  physical  struc- 
ture; and  though  an  acid  acts  more  rapidly  on  the  latter  than  on 
the  former,  yet  the  result  of  the  action  is  the  same.  An  acid,  too, 
will  act  with  more  energy  on  a  soft,  porous  tooth,  than  on  one  of 
firmer  texture;  yet  the  chemical  results  are  the  same  It  is  safe 
to  conclude,  then,  that  as  there  are  but  few  results  in  the  chemical 
actions  attendant  on  dental  caries,  there  are  but  few  chemical 
agents  immediately  concerned  in  their  production. 

It  is  not  to  be  inferred  from  the  above  that  but  few  agents  are 
capable  of  injuring  the  teeth  by  chemical  action.  Many  acids 
used  in  food  or  as  medicines  are  capable  of  doing  injury  to  the 
teeth.  But  no  one  need  suppose  that  an  acid,  even  though  con- 
siderably concentrated,  brought  occasionally  in  contact  with  the 
teeth,  is  the  immediate  cause  of  caries.  Every  close  observer  will 
conclude  that  caries  is  the  result  of  an  agent  acting  slowly  and 
steadily  in  the  accomplishment  of  its  work.  He  will  be  apt  to  infer 
that  this  agent  is  either  formed  by  chemical  action  within  the 
mouth,  or  is  eliminated  therein,  either  as  a  secretion  or  an  excre- 
tion, and  that  it  quietly  performs  its  disastrous  deeds  as  fast  as 
formed  or  eliminated.  The  application  to  the  teeth  of  an  acid 
capable  of  acting  chemically  on  them,  facilitates  or  predisposes  to 
the  production  of  caries;  and  this  it  may  do  without  this  acid 
being  the  immediate  cause  of  the  decay.  A  tooth  may  be  frac- 
tured, or  its  enamel  be  removed,  by  mechanical  means ;  and  as  the 
dentine  is  thus  exposed,  the  tooth  is  more  liable  to  caries  than 
before  the  exposure.  But  no  one  supposes  that  the  mechanical 
action  which  exposes  the  dentine  is  the  immediate  cause  of  the 


DENTAL    CARIES.  479 

caries.  The  dentine  would  remain  sound  and  healthy  did  not 
some  chemical  agent  attack  it.  In  like  manner,  in  the  administra- 
tion of  acids  as  food  or  medicine,  the  teeth  may  be  so  corroded  as 
to  expose  the  dentine,  and  render  it  as  liable  to  the  action  of  the 
carious  agent  as  in  the  former  case ;  or  if  the  dentine  is  not 
exposed,  the  enamel  may  be  roughened,  either  mechanically  or 
chemically,  so  as  to  afford  a  lodgment  for  organic  matter,  which,  by 
decomposition,  may  generate  one  of  the  acids  immediately  con- 
cerned in  the  production  of  caries.  On  this  principle,  acid  medi- 
cines and  acid  foods  may  indirectly,  but  not  immediately,  cause 
caries.  The  same  remarks  will  apply  to  acids  brought  in  contact 
with  the  teeth  by  eructation  or  vomiting. 

If  this  view  is  correct,  the  investigation  of  the  subject  of  dental 
caries  is  brought  within  a  narrower  compass  than  many  suppose. 
The  first  step  is  to  iuquii'e  what  acids,  in  health  and  disease,  are 
liable  to  be  secreted  or  excreted,  so  as  to  be  brought  regularly  in 
contact  with  the  teeth.  The  second  is  to  ascertain  what  acids  are 
liable  to  be  formed  within  the  mouth  by  fermentation  or  otherwise. 
And  the  third  is  to  discover  what  ones  of  all  these  are  capable  of 
producing  the  phenomena  of  dental  caries.  There  is  but  little  room 
to  doubt  tliat,  at  least,  each  of  the  first  three  varieties  is  the  result 
of  a  specific  agent. 

To  properly  understand  any  chemical  action  to  which  the  teeth 
are  subject,  it  is  necessary  to  bear  in  mind  their  texture  and  com- 
position, and  to  consider  the  chemical  properties  of  at  least  their 
principal  constituents.  It  must  also  be  remembered  that  the  teeth 
are  endowed  with  vitality.  As  dental  caries — the  most  common 
disease  of  the  human  race — is  now  universally  conceded  to  be  the 
result  of  chemical  action,  the  importance  of  this  subject  is  at  once 
manifest.  The  time  is  not  far  distant  when  in  every  case  of  recent 
caries,  the  enlightened  practitioner  will  be  able,  by  the  character 
of  the  decay  and  the  habits  and  constitution  of  the  patient,  to 
detect  and  identify  the  agent  or  agents  producing  the  disease. 
Any  practice  short  of  this  knowledge  must  be,  at  least  to  some  ex- 
tent, guesswork,  and  is,  although  the  best  we  can  now  do,  empirical 
practice. 

The  fact  that  an  active  alkaline  base  is  the  principal  inorganic 


480  APPENDIX. 

ingredient  of  the  teeth,  would  indicate  clearly  that  their  great 
danger  lies  in  the  presence  of  acids ;  and  all  experience  demon- 
strates the  truth  of  this  inference.  This  danger  is  also  greater 
from  the  fact  that  the  principal  salt  of  this  base,  present  in  the 
tooth-substance,  combines  with  several  acids  without  undergoing 
decomposition. 

It  is  evident  that  the  acids  do  not  all  act  alike  on  the  teeth. 
Indeed,  some  exert  no  influence  whatever  on  them,  while  others 
act  with  great  energy  on  each  and  all  of  their  constituents.  It 
would  be  an  endless  task  to  consider  all  the  substances  which  are 
capable  of  exerting  an  injurious  chemical  influence  on  the  teeth ; 
and  perhaps  it  would  be  as  unprofitable  as  endless.  All  that  is 
now  aimed  at  is  an  accurate  account  of  the  various  substances  which 
ordinarily  act  chemically  on  the  teeth — which  produce  caries  and 
"  chemical  abrasion." 

Without  further  preface,  we  will  proceed  to  notice  some  of  the 
the  chemical  agents  alluded  to. 

Nitric  Acid. — This  acid  is  composed  of  five  equivalents  of  oxy- 
gen united  with  one  of  nitrogen.  Its  symbol  is  therefore,  NO^. 
It  acts  with  great  energy  on  all  the  constituents  of  the  tooth.  Its 
great  energy  of  action  depends  on  a  variety  of  circumstances.  As 
an  acid,  it  unites  energetically  with  bases,  and  will,  therefore,  take 
the  lime  and  kindred  bases  from  the  weaker  acids.  From  its  ready 
decomposition,  it  affords  oxygen,  in  its  nascent  condition,  for  the 
destruction  of  oxydizable  substances.  Its  action  on  the  tooth  may 
be  thus  briefly  described :  it  dissolves  the  phosphate  of  lime,  de- 
composes the  carbonate,  setting  the  carbonic  acid  free,  and  forming 
nitrate  of  lime,  and  destroys  the  organic  portion,  producing  a 
highly-softened  state  of  the  carious  matter.  In  fact,  it  is  a  promi- 
nent, if  not  the  principal,  agent  in  the  production  of  the  "  white 
decay." 

But  the  question  naturally  arises.  Is  an  agent  so  destructive  in 
its  tendencies  likely  to  come  in  contact  with  the  teeth,  and  if  so, 
under  what  circumstances  ?  The  ({uestion  is  important,  and  the 
answer,  perhaps,  diflBcult. 

It  is  well  known  that  this  acid  is  frequently  administered  as  a 
tonic;  and  it  is  a  lamentable  fact  that  far  too  little  attention  is  paid 


t 


DENTAL   CARIES.  481 

to  the  prevention  of  its  injurious  effects  on  the  teeth  io  such  cases, 
but  this  will  by  no  means  account  for  the  frequency  with  which  it 
evidently  injures  the  dental  organs.  A  few  thoughts  in  regard  to 
its  formation  may  throw  some  light  on  the  subject. 

It  is  a  singular  fact  that  though  nitrogen  and  oxygen  manifest 
but  little  affinity  for  each  other,  yet  they  unite  in  various  propor- 
tions, forming  at  least  five  well-known  distinct  compounds.  It 
appears,  however,  from  a  variety  of  circumstances,  that  their  ten- 
dency is  to  unite  in  the  proportions  which  form  nitric  acid.  The 
protoxyd  is  readily  decomposed,  and  yields  nitrogen,  oxygen,  and 
nitrous,  acid.  The  binoxyd,  if  brought  in  contact  with  the  atmos- 
phere, takes  from  it  two  equivalents  of  oxygen,  and  also  becomes 
nitrous  add,  or  NO^.  Hyponitrous  acid,  NO3,  on  admixture  with 
water,  is  converted  into  nitric  acid  and  binoxyd  of  nitrogen,  thus : 
3N03=N05+2N02.  in  which  case  the  latter  will  be  converted  into 
nitrous  acid,  which,  in  the  presence  of  water,  is  converted  into 
nitric  acid  and  binoxyd  of  nitrogen. 

It  follows  from  this  that,  if  oxygen  and  nitrogen  unite  at  all  in 
the  mouth,  let  the  proportions  be,  at  the  first,  what  they  will,  nitric 
acid  must  be  the  ultimate  result — as  air  and  moisture,  the  only 
agents  necessary  in  the  transformation,  are  here  always  present. 

The  reader  will  now  think  of  the  mucus,  and  particles  of  nitro- 
genous food  lodged  about  the  teeth  undergoing  decomposition,  and 
3delding  nitrogen  to  the  oxygen  of  the  atmosphere,  or  of  the  fluids 
of  the  mouth,  and  will  conclude  that  all  is  explained.  Well,  per- 
haps it  is.  But  let  us  consider.  Nitrogen  is  emphatically  a  "  con- 
servative" element,  and  manifests  but  little  tendency  to  unite  with 
anything,  and  especially  with  oxygen.  It  is  probable,  therefore, 
that  these  two  elements  unite  indirectly.  It  should  be  borne  in 
mind  that  organic  nitrogenous  bodies  contain  hydrogen  and  oxy- 
gen, as  well  as  nitrogen.  Consequently,  by  their  decomposition, 
these  elements  are  all  liberated.  The  mutual  affinities  of  hydrogen 
and  nitrogen  take  precedence,  and  the  result  is  the  formation  of 
ammonia,  NH3.  But  ammonia  exposed  to  the  action  of  oxygen  is 
always  decomposed ;  an  oxyd  of  nitrogen  is  formed,  and  of  course 
niti'ic  acid  is  the  result. 

With  this  view  of  the  case,  and  from  the  fact  that  many  persons 

FF 


482  APPENDIX. 

permit  the  buccal  mucus  as  well  as  particles  of  nitrogenous  food  to 
remain  around,  upon,  and  between  the  teeth,  till  decomposition  is 
eflPected,  it  is  not  surprising  that  the  white  variety  of  dental  caries 
is  so  frequently  found. 

Nitric  acid  is  also  sometimes  formed  in  the  mouth  by  the  agency 
of  galvanic  action.  When  two  metals  are  placed  in  the  mouth  in 
proximity  to  each  other,  and  the  fluids  of  the  mouth  are  capable  of 
acting  on  one  of  them,  galvanic  action  is  established.  And  if  they 
are  so  situated  that  the  mucus  membrane  forms  a  connecting  con- 
ductor, by  being  in  contact  with  both,  especially  if  the  metallic 
surfaces  be  considerable,  a  current  is  established  sufficient  to 
decompose  any  of  the  binary  compounds  contained  in  these  fluids. 
The  liberated  nitrogen,  hydrogen,  and  oxygen  will  result,  as  above, 
in  the  formation  of  ammonia,  and  then  nitric  acid.  But  galvanic 
action  in  the  mouth  is  more  likely  to  develop  hydrochloric  than 
nitric  acid.     This  will  be  noticed  again. 

Sulphuric  Acid. — Sulphuric  acid  is  composed  of  16  parts  of 
sulphur  united  with  24  of  oxygen.  Its  symbol  is,  therefore  SO,. 
In  addition  to  those  properties  which  characterize  it  as  an  acid,  it 
is  a  powerful  caustic  poison,  and  promptly  destroys  the  various 
tissues  with  which  it  comes  in  contact.  Its  cliemical  action  on 
ordinary  tissues  depends  principally  on  its  affinity  for  water,  but 
not  altogether;  for  it  has  the  ability  to  coagulate  and  unite  with 
albumen,  and  to  dissolve  fibrin.  In  common  with  other  acids,  it 
has  a  strong  affinity  for  alkaline  bases. 

With  these  properties  in  view,  let  us  examine  its  action  on  the 
teeth. 

The  affinity  of  this  acid  for  water  is  so  energetic  that  it  seems 
even  to  force  its  elements  to  forsake  favorite  combinations,  and  to 
unite  with  each  other,  that  it  may  be  gratified.  For  example,  a 
cork  in  a  bottle  of  sulphuric  acid  becomes  dark-colored,  and  is 
really  charred.  Now  a  cork,  like  other  wood,  is  mainly  composed 
of  carbon,  hydrogen,  and  oxygen — the  latter  two  being  in  the 
proper  proportions  to  form  water.  Their  affinity  for  each  other, 
quickened  by  that  of  the  acid  for  the  result  of  their  combination, 
causes  them  to  forsake  the  carbon,  unite  with  each  other  to  form 
water,  and  then  combine  with  the  acid.     The  same  phenomena 


DENTAL   CARIES.  483 

occur  when  it  acts  on  animal  tissues;  for  they  are  principally  com- 
posed of  the  above-named  elements,  with  the  addition  of  nitrogen. 
Accordingly,  "  black  spots  are  frequently  observed  in  the  stomachs 
of  those  who  have  swallowed  the  acid."  Now,  that  its  slow  and 
prolonged  action  on  the  gelatinous  portion  of  the  tooth  would 
result  in  its  carbonization,  is  a  conclusion  justified  both  by  infer- 
ence and  experiment.  But  carbonized  gelatin  is  "  animal  charcoal," 
the  color  of  which  is  a  prominent  characteristic  of  "  black  decay." 

The  phosphate  of  lime  in  the  tooth,  which  is  not  the  neutral, 
but  a  subphosphate,  is  not  soluble  in  sulphuric  acid ;  nor  is  the 
acid  capable  of  decomposing  it,  except  in  the  presence  of  alcohol. 
It  follows,  then,  that  this  acid  does  not  break  down  the  texture  of 
the  tooth  to  the  extent  that  some  others  do,  simply  because  it  can- 
not unite  with,  or,  under  ordinary  circumstances,  decompose  the 
principal  earthy  salt  of  which  it  is  composed.  And  here  we  have 
a  second  characteristic  of  "  black  decay." 

It  is  now  time  to  inquire  whether  at  all,  and  if  so,  by  what 
means,  and  under  what  circumstances,  this  acid  is  brought  in  con- 
tact with  the  dental  organs. 

Sulphuric,  like  nitric  acid,  is  frequently  administered  as  a  med- 
icine, and  generally  with  criminal  negligence  in  respect  to  its 
action  on  the  teeth.  But  we  cannot  regard  this  as  the  only  or 
principal  source  of  danger  from  this  acid.  If  oxygen  unites  at  all 
with  sulphur,  the  tendency,  under  ordinary  circumstances,  is  to 
the  formation  of  sulphuric  acid,  as  sulphurous  acid  in  the  presence 
of  moisture  is  rapidly  converted  into  the  sulphuric.  The  whole 
question,  then,  is  reduced  to  this,  Is  sulphur  ordinarily  present  in 
the  mouth,  and  liable  there  to  become  oxydized '( 

Albumen  is  a  constituent  of  mucus,  and  is  contained  in  many 
articles  of  food.  Sulphur,  if  not  a  constituent  of,  is  always  united 
with  albumen.  Its  ordinary  presence  in  the  mouth  is  thcrefjre 
easily  explained.  Sulphur  and  oxygen  unite  directly,  under 
various  circumstances,  as  in  the  combustion  of  sulphur ;  but  it  is 
probable  that  the  union  here  is  effected  by  indirect  means.  Hy- 
drosulphic  acid,  or  sulphuretted  hydrogen,  is  one  of  the  results  o\ 
the  putrefactive  decomposition  of  albuminous  substances.  The 
breaths  of  our  patients  often  bear  ample  testimony  to  its  presence 


484  APPENDIX. 

ia  the  mouth.  Now,  the  oxygen  of  the  atmosphere  rapidly  decom- 
poses this  acid  by  taking  its  hydrogen  to  form  water.  The  sulphur 
is  therefore  set  free,  and  being  in  its  nascent  state,  its  aflBnities  are 
increased  in  energy,  and  it  also  unites  with  oxygen,  forming  sul- 
phurous acid,  SOj,  which  in  the  presence  of  the  water  of  the  saliva 
is  rapidly  converted  into  sulphuric  acid,  or  SO3. 

The  quantity  of  sulphur  present  in  the  mouth  at  any  one  time 
is  very  minute ;  and  a  great  proportion  of  this  is  exhaled  by  the 
breath  before  it  has  time  to  undergo  decomposition.  And  sul- 
phuric acid,  as  already  noticed,  has  a  weaker  affinity  for  the  con- 
stituents of  the  tooth  than  some  others.  Hence  "  black  decay"  is 
not  so  frequently  met  with  as  some  other  varieties.  And  as  from 
the  nature  of  the  chemical  action  the  texture  of  the  tooth  is  not  so 
entirely  broken  up,  the  carbonized  portion  protects  the  parts 
beneath  it.  This  variety  of  decay  therefore  progresses  less  rapidly 
than  others. 

Hi/drochloric  Acid. — This  acid  is  also  called  chloro-hydric  and 
muriatic  acid.  It  is  composed  of  35  parts  of  chlorine,  united  with 
1  of  hydrogen.  Its  symbol  is  HCl.  Though  its  elements  manifest 
a  strong  affinity  for  each  other,  yet  it  is  very  readily  decomposed ; 
and  many  of  its  chemical  manifestations  result  from  the  action  of 
one  or  both  of  its  liberated  elements.  It  is  on  this  principle  the  acid 
attacks  metals — being  decomposed,  the  chlorine  unites  with  the  metal 
to  form  a  chloride,  and  the  hydrogen  escapes  with  effervescence. 

This  acid,  like  those  previously  considered,  is  a  caustic  poison. 
Its  escharotic  power  depends  mainly  on  its  affinity  for  water, 
which  is  very  active,  and  on  its  ability  to  coagulate  albumen.  Its 
chemical  action  is  generally  inferior  to  that  of  the  two  acids  just 
consideed.  It  unites  with  bases,  forming  a  class  of  salts  called 
hydrochlorates ;  and  sometimes  it  combines  with  a  salt  without 
decomposing  it,  or  being  itself  decomposed.  When  concentrated, 
it  dissolves  animal  tissues,  but  is  in  this  respect  fiir  inferior  to 
nitric  acid.  When  much  diluted  and  mixed  with  dried  mucous 
membrane,  it  dissolves  coagulated  albumen,  fibrin,  etc.,  performing 
to  all  appearance  an  artificial  digestion. 

A  careful  observation  of  these  properties  will  enable  us  to  under- 
stand the  action  of  this  acid  on  the  tooth. 


DENTAL    CARIES.  485 

The  carbonate  of  lime  and  the  acid  are  mutually  decomposed. 
The  results  are  chloride  of  calcium,  water,  and  carbonic  acid.     The 
decomposition  may  be  represented  by  the  following  equation  : 
CaO,CO,  +  HCl=CaCl  +  HO+CO,. 

The  carbonic  acid  of  course  escapes  as  a  gas,  and  the  chloride, 
being  very  soluble,  is  dissolved  in  the  saliva,  and  thus  removed  from 
the  tooth. 

The  phosphate  of  lime  (bone  phosphate),  though  not  decom- 
posed by,  is  highly  soluble  in  hydrochloric  acid.  It  is  dissolved, 
and  is  thus  removed  from  the  organic  portion  of  the  tooth. 

We  have  seen  that  this  acid,  unless  highly  concentrated,  is  not 
capable  of  dissolving  the  animal  portion  of  the  tooth.  As  this  con- 
centration is  not  likely  to  take  place  in  the  mouth,  it  follows  that, 
when  hydrochloric  acid  is  the  cause  of  dental  caries,  the  earthy 
portion  is  dissolved  and  removed,  while  the  animal  portion  princi- 
pally remains  in  the  carious  cavity.  And  here  we  have  the  promi- 
nent characteristics  of  a  third  variety  of  decay. 

I  have  not  taken  into  the  account  any  of  the  earthy  salts  con- 
tained in  the  tooth,  but  the  phosphate  and  carbonate  of  lime. 
They  are  present  in  such  small  quantities  that  they  exert  but  little 
influence  on  any  of  the  chemical  actions  which  we  have  considered. 

Hydrochloric  acid  is  also  administered  as  a  medicine;  and  the 
remarks  made  on  the  preceding  acids  apply  equally  here.  Thi.s 
acid  is  an  ingredient  of  the  gastric  fluid,  and  is  often  present  in 
abnormal  quantities  in  the  stomach,  from  which  it  is  thrown  into 
the  mouth  by  eructation  and  vomiting.  But  we  cannot  thus 
account  satisfactorily  for  the  frequency  with  which  the  dental 
organs  are  evidently  injured  by  this  acid. 

Thouah  in  its  normal  state  the  saliva  is  alkaline,  yet  in  a  variety 
of  abnormal  conditions  it  contains  one  or  more  free  acids;  and  the 
hydrochloric  is  one  of  those  most  frequently  present.  It  often 
originates  no  doubt  in  the  decomposition  of  the  soluble  chlorides 
contained  in  the  saliva  and  mucus.  When  the  chlorine  of  these  is 
liberated,  it  takes  hydrogen  from  the  water  of  the  saliva,  and  this 
acid  is  a  result  of  the  union. 

But  sometimes  hydrochloric  acid  is  directly  furnished  by  the 
salivary  glands,  either  as  a  secretion  or  an  excretion.     The  system 


486  APPENDIX. 

may  contain  just  its  normal  quantity  of  chlorine,  but  if  there  be  a 
deficiency  of  sodium  or  potassium,  the  relative  excess  of  chlorine  is 
converted  into  hydrochluric  acid.  In  this  case  the  acid  is  secreted. 
Or  the  quantity  of  potassium,  and  sodium  may  be  normal,  with  an 
excess  of  chlorine.  The  excess  will  unite  as  before  with  hydrogen, 
and  the  acid  will  be  excreted.  At  all  events,  this  acid  is  usually 
found  in  the  mouth  when  the  mucous  membrane  is  inflamed,  as 
well  as  in  patients  who  indulge  in  the  excessive  use  of  salted 
meats. 

Galvanic  currents  in  the  mouth  always  result  in  the  formation  of 
this  acid.  The  chlorides  of  sodium  and  pot.issium,  present  in 
normal  mucus  and  saliva,  are  decomposed,  and  their  chlorine  unites 
with  hydrogen  derived  from  the  water  of  the  saliva.  It  is  on  this 
principle  that  we  frequently  find  a  decayed  surface  around  a  gold 
filling,  which  is  in  close  proximity  with  one  of  a  diflPerent  metal,  or 
with  a  silver  plate  or  clasp.  In  such  decays,  the  animal  portion 
usually  remains,  while  the  earthy  portion  is  removed,  just  as  would 
be  expected  from  the  prolonged  action  of  dilute  hydrochloric  acid. 

In  these  observations  we  have  endeavored  to  set  forth  the  results 
of  the  ordinary  uninterrupted  action  of  these  acids  on  the  teeth ; 
and  we  have  seen  that  they  are  capable  of  producing  the  three 
varieties  of  decay  usually  described,  though  we  by  no  means  main- 
tain that  they  are  the  only  agents  capable  of  causing  these  results. 
Their  actions,  and  con.sequently  the  characteristics  of  decay  pro- 
duced by  them,  are  doubtless  much  modified  by  circumstances. 
One  of  them  may  be  the  destructive  agent  in  the  commencement 
of  the  caries,  and,  in  process  of  time,  another  may  be  developed, 
and  exert  its  specific  influence  on  the  same  cavity.  Then  the  phe- 
nomena would  of  course  be  complex.  Again,  it  should  be  remem- 
bered that  a  strong  affinity  for  water  is  a  jiroperty  common  to  all 
of  them.  It  is  possible  therefore  that  carbonization  or  blackening, 
may  result  from  the  action  of  any  of  them,  yet  it  is  by  no  means 
probable,  at  least  with  nitric  acid. 


DR.    palmer's    plugging    INSTRUMENTS.  487 


SECTION    B.— DR.    CORYDON    PALMER'S    PLUGGING 
INSTRUMENTS. 

In  the  followinir  pages  are  given  a  description,  and  the  mode  of 
using  Dr  Pahiier's  very  complete  set  of  plugging  instruments. 

They  are  illustrated  in  this  volume,  page  136  (Fig.  55).  The 
manner  of  using  them  is  so  explicitly  given  in  these  pages,  that  no 
one  of  experience  in  the  use  of  instruments  can  fail  to  apply  them 
as  intended. 

They  constitute,  altogether,  the  most  perfect  set  of  plugging  in- 
struments ever  devised.  They  more  nearly  meet  every  case,  that 
may  be  presented,  than  anything  heretofore  used. 

Several  instruments,  accessory  to  the  set,  are  here  described, 
that  are  not  illustrated  in  this  volume ;  they  are  all,  however,  very 
valuable,  and  exactly  adapted  to  the  purpose  for  which  they  were 
designed.  T. 

In  the  designing  of  these  instruments  for  the  profession,  it  has 
been  my  aim  to  perfect  a  set  that  shall  enable  the  operator  to  reach 
with  mallet  force  any  case  that  maybe  presented. 

A  course  of  practical  experiments  dating  back  to  the  introduc- 
tion of  the  use  of  the  mallet,  has  brought  me  to  the  present  designs. 

In  conducting  the  course,  my  object  has  been — First,  to  get  the 
best  adaptations ;  second,  to  have  as  few  curves  as  possible ;  and 
third,  the  least  number  of  instruments  that  will  do  all  the  work  ;  and 
lastly,  to  have  the  size  and  length  of  each  instrument  proportionate 
to  its  use. 

There  is  no  one  thing  that  we  owe  so  much  to  our  fellow-prac- 
titioners as  to  give  to  each  credit  for  what  he  does  toward  the 
improvement  and  elevation  of  our  science. 

For  my  own  part,  I  do  not  claim  entire  originality  in  the  forms 
of  my  instruments.  For  principles,  I  am  indebted  to  our  worthy 
friend,  William  II.  Atkinson,  and  for  valuable  interchanges  to 
Charles  R.  Butler. 

All  instruments  for  mallet  forces  can  be  but  modifications  of  the 
foot.     My  efibrts  have  been  to  produce  a  mallet  set,  to  be  used  in 


488  APPENDIX. 

their  numerical  order,  that  shall  indicate  a  systematic  course  of 
operating. 

The  plugging  set  co7isists  of  iliirty-five  pieces.  Up  to  No.  16, 
they  pertain  to  the  incisors ;  and  I  would  especially  recommend 
that  they  be  used  only  upon  these  teeth.  The  tendency  will  be  to 
use  thoni  in  every  case ;  but  it  is  too  much  risk  for  such  fine 
points. 

Do  not  pick  up  the  gold  upon  the  point  of  the  instrument  and 
hold  it  in  the  lamp,  as  it  will  quickly  destroy  the  temper. 

From  No.  17  to  30,  the  instruments  pertain  to  the  bicuspids 
and  molars. 

In  order  to  describe  the  instruments,  we  must  suppose  a  case : 

Left  superior  central,  anterior  approxinial  surface,  cavity,  pre- 
pared with  fine  retaining  pits  at  each  angle  of  the  cervical  wall. 

The  first  three  in  the  order  of  their  arrangement  are  cutting  in- 
struments, and  designated  by  dots  to  distinguish  them  from  the 
plugtrers.  'J  he  first  one  is  a  fine  elastic  drill,  for  retaining  pics. 
The  second  is  a  fine  scoop  for  clearing  the  pit.  The  third  is  a 
curved  side-cut,  for  clearing  the  last  par  icles  from  the  cavity 
proper.  These  three  instruments  are  indispensable  to  the  last  pre- 
parati(jn  of  the  cavity,  and  must  necessarily  be  clas-ified  with  the 
pluggers  for  the  present;  but  it  is  my  intention  that  they  shall 
comprise  the  last  and  higher  numbers  of  a  systematic  set  of  cutting 
instruments  to  be  brought  forward  in  due  course  of  time. 

The  two  instruments  Xo.  0,  are  holdere  for  keeping  the  gold  in 
position  until  it  can  be  tacked  fast.  The  one  with  a  guard  in  the 
centre  is  to  be  used  when  no  assistant  is  at  hand ;  and  when  held 
between  the  first  and  second  fingers,  the  guard  is  designed  to  pre- 
vent the  fingers  from  slipping  down.  The  rounded  top  will  be  use- 
ful upon  which  at  times  to  rest  the  forefinger  of  the  left  hand  at 
the  first  joint,  and  help  to  regain  position  of  the  fingers. 

Holders  are  important  instruments,  not  familiar  to  all.  I  would 
draw  attention  to  their  use.  I  feel  a  particular  pride  in  this  one 
new  design.  It  is  purposely  short,  in  order  to  bring  it  more  easily 
under  control ;  and  having  the  guard,  will  enable  the  operator  to 
Iiold  it  and  the  plugger  in  one  hand,  at  the  saTie  time. 

The  m  inner  of  retaining  is  to  place  the  holder  between  the  first 


DR.    palmer's    plugging    INSTRUMENTS.  489 

and  second  fingers  of  the  left  hand,  letting  them  rest  upon  the 
guard,  and  place  the  plugger  between  the  thumb  and  forefinger, 
letting  the  points  of  the  instrument  cross  in  the  cavity. 

No.  0,  without  a  guard,  is  to  be  used  when  the  help  of  an  assis- 
tant is  at  hand,  and  taken  up  at  choice. 

The  two  holders  and  the  plugger  may  form  at  times  a  useful 
trio.  Used  without  an  assistant,  the  three  can  be  held  in  position 
by  the  left  hand,  and  the  stroke  given  by  the  right;  or,  with  assist- 
ant help,  the  two  holders  in  the  left  and  the  plugger  in  the  right 
hand. 

The  manner  of  holding  th'^  three  in  one  hand  is  to  place  the  two 
holders  in  position,  as  above  described,  and  then  add  the  plugger 
between  the  thumb  and  forefinger,  in  front  of  the  holders,  letting 
the  points  come  in  position.  With  assistant  help,  the  two  holders 
are  held  in  position  as  abovr,  and  the  plugger  held  in  the  right 
hand. 

I  do  not  wish  to  be  understood  that  the  holder  is  to  be  used 
throughout  an  entire  operation  ;  but  that  in  the  starting  of  a  filling, 
it  is  indispensable,  and  at  other  times  useful,  as  may  be  indicated. 

No.  1,  Pit  Point,  is  to  introduce  the  first  pieces  of  gold  into  the 
retaining  pits,  and  fill  all  minute  cavities  upon  the  labial  surfaces, 
where  ease  of  access  and  direct  force  can  be  had. 

No  2,  Small  Poof,  is  to  introduce  the  first  pieces  of  gold  after 
the  pits  are  filled,  and  is  to  be  applied  until  the  gold  is  made  to 
extend  from  one  pit  to  the  other  and  firmly  attached. 

No.  3,  Poot,  is  to  add  a  portion  after  No.  2,  and  do  the  burthen 
of  the  work  in  filling  the  cavity  even  with  the  edges  of  the  wall. 

No.  4,  Poot,  is  to  be  used  to  lay  the  gold  along  the  cervical  wall, 
by  letting  the  heel  pass  into  the  cavity,  and  the  point  project 
obliquely  beyond  the  edge  of  the  wall,  so  as  to  carry  the  gold  hard 
upon  and  perfectly  along  its  whole  line. 

No.  5,  Curved  Poof,  is  to  apply  upon  the  inner  surface  of  the 
labial  wall,  by  opening  the  mouth  and  applying  it  direct  from  the 
lingual  surface.  Its  curved  point  will  admit  of  its  being  brought 
in  contact  with  the  wall  with  less  danger  of  fracture  than  the  plane 
foot.  It  also  has  a  working  point,  which  may  be  applied  with 
directing  force  with  advantage. 


490  APPENDIX. 

No.  6,  Doiihlfi  Srmtfe(f  Pit  Point,  is  to  carry  tlie  <:old  into  the 
apex  of  the  cavity,  toward  the  cuttinji;  edge  of  the  tooth.  This 
instrument  deserves  especial  notice.  It  enables  the  operator  to 
carry  the  gold  with  mallet  force  into  this  part  of  the  cavity  with 
ease  and  certainty.  It  must  be  used  with  ctireful  dircrtincj  force, 
and  can  be  applied  either  from  the  labial  or  lingual  surface. 

No.  7,  Slot  Plugger.,  applies  in  filling  the  slot,  extending  from 
the  apex  of  the  cavity  to  and  along  the  line  of  the  cutting  edge, 
or  wherever  slots  occur  upon  the  incisors. 

No.  8,  Lingual  Modeler,  applies  in  modeling  up  the  lingual 
ridges  of  the  incisors.  Its  form  enables  the  operator  to  hold  the 
point  to  or  from  him,  without  danger  of  impigning  upon  the  ad- 
joining tooth.  By  opening  the  mouth,  direct  force  can  be  given. 
It  will  be  observed  that  this  and  several  of  the  other  instruments 
are  sloped  forward  in  the  handle,  in  order  to  favor  their  introduc- 
tion from  the  lingual  surface. 

No.  9,  Lingual  Malht  Burnisher,  applies  in  the  last  condensing 
of  the  gold,  along  the  lingual  edges  of  the  cavity.  Held  at  an 
angle  bringing  it  to  bear  upon  one  of  its  sloping  faces,  it  can  be 
made  to  glide  along,  or  bringing  the  point  more  to  bear  will  follow 
minute  lines,  as  may  be  desired. 

No.  10,  Curved  Cervical  Modeler,  applies  in  modeling  the  gold 
at  the  cervical  wall  of  both  the  incisors  and  bicuspids ;  is  indispen- 
.sable  for  condensing  the  anterior  and  posterior  surfaces  of  bicuspid 
fillings.  It  will  be  found  to  reach  these  surfaces  most  admirably. 
By  applying  it  as  the  operation  progresses,  the  approximal  surfaces 
may  be  modeled  into  form. 

No.  11,  Curved  Aj)jn-oximal  Modeler,  applies  upon  the  approx- 
imal surface  of  the  gold,  after  the  cavity  is  filled  even  with  the 
edges  of  the  walls,  and  does  all  the  remainder  of  the  modeling  of 
this  part  of  the  filling.  The  gold  is  to  be  laid  on  in  flat  pieces,  and 
the  instrument  applied,  both  from  the  labial  and  lingual  surfaces. 
Its  curve  enables  the  operator  to  pass  it  through  so  far  between  the 
teeth  as  to  easily  reach  all  parts  of  the  approximal  surface.  This 
instrument  forms  a  marked  feature  in  the  set,  and  becomes  a  great 
favorite. 

No.  12,  Curved  Crown  Modeler.     This  instrument  applies  upon 


I 


I 


DR.    palmer's    plugging    INSTRUMENTS.  491 

the  cutting  edges  of  the  incisors  and  the  elongation  of  their  crowns, 
and  upon  all  the  teeth  where  direct  force  is  required  upon  a  flat 
surface. 

X^Q  13,  Cxtrved  Cuxp  Modehr.  In  the  operation  of  elongating 
the  crowns  of  the  incisors,  the  labial  and  lingual  surfaces  of  the 
gold  must  be  condensed,  as  the  operation  progresses.  Direct  force 
is  not  admissible,  and  this  instrument,  held  ■  t  an  angle,  meets  the 
ease.     It  is  also  designed  to  model  cusps  and  fissures. 

Xo.  14,  Curved  Model  Separator^  applies  with  mallet  force  in 
effecting  a  separation  between  approximal  fillings  in  the  incisors, 
and  can  be  introduced  from  the  labial  or  lingual  surfaces,  as  the 
Civse  may  require. 

Xo.  15,  Side  Carved  Hand  Separator.  Useful  in  eff"ecting  a 
separation  of  the  fillings,  same  as  No.  14. 

Xo.  IG,  Curved  Hand  Burnisher.,  for  the  last  condensing  and 
finish  of  the  filling  in  the  incisors. 

Xos.  17  and  IS.  Foot  Instruments,  are  the  same  size  upon  their 
working  faces  as  Nos.  2,  and  3,  and  are  to  take  their  place  upon 
the  bicuspids  and  molars.  Being  designed  to  do  the  burthen  of 
the  work,  they  are  made  stouter,  and  with  less  angle  of  face,  and 
less  inner  curve. 

Xo.  10,  Foot,  is  designed  to  lay  the  gold  upon  the  cervical  walls 
of  the  bicuspids  and  molars,  by  passing  the  heel  into  the  cavity, 
and  letting  the  point  project  beyond  the  edge  of  the  cervical  wall. 
Same  as  the  use  of  No.  4. 

Xo.  20,  Curved  Foot,  applies  upon  the  thin  curved  buccal  and 
lingual  walls  of  the  bicuspids  and  molars. 

Xo.  21,  Slot  Pluggers,  used  wherever  slots  occur  upon  the  bicus- 
pids and  molars. 

Xo.  22,  Dovhle-curved  Holder,  for  the  bicuspids  and  molars,  and 
wherever  a  curved  holder  is  required. 

Xo.  23,  Double-curved  Root  Plugger,  used  with  directing  force 
in  the  palatal  roots  of  the  superior  molars,  and  in  all  cases  where 
large  deep  root  cavities  occur.  It  is  the  first  of  a  class  of  eight 
instruments,  purposely  designed  of  a  larger  size  than  the  previous 
numbers,  in  order  to  enable  the  operator  at  times  to  grasp  the 
instrument  firmly  in  the  whole  hand,  and  give  directing  force. 


492  APPENDIX. 

No.  24,  Double-curved  Croze-pointed  Plugr/er,  applies  in  the 
deep  angles  of  the  posterior  cavities  of  the  inferior  bicuspids  and 
molars.     Used  with  firm  directing  force. 

No.  25,  Curved  Molar  Foot,  has  a  working  point,  and  is 
designed  to  introduce  all  the  gold  into  the  inferior  central  crown 
cavities  of  the  molars.  It  applies  with  the  use  of  the  holder,  by 
first  securing  the  gold  in  the  most  deep,  distal  part  of  the  cavity, 
and  then  working  forward,  extending  the  gold  along  the  sides  of  the 
cavity,  until  the  centre  is  passed,  and  then  turning  the  point  of  the 
instrument  and  working  backward  until  the  walls  of  the  cavity  are 
entirely  lined  up;  then  commence  and  bring  up  the  centre  of  the 
filling  to  finish.  This  instrument  is  one  of  the  most  universally- 
acting  and  rapid-working  points  with  which  I  am  acquainted.  It 
admits  of  being  turned  to  and  from  the  operator,  and  works  across 
the  mouth  with  great  advantage.  The  position  for  the  operator 
for  the  right  inferior  molar  is  back  of  and  above  the  patient.  For 
the  left,  if  the  operator  is  skilled  in  the  use  of  the  left  hand,  he 
need  not  change  positions;  but  if  change  is  required,  stand  at  the 
left  side  and  hold  the  instrument  with  firm  directing  force. 

Nos.  26  and  27,  Right  and  Left  Treble-curved  Bicuspid  Plwj- 
grrs,  are  designed  to  introduce  the  gold  into  the  posterior  cavities 
of  the  inferior  bicuspids  and  molars.  The  opinion  has  largely  pre- 
vailed that  direct  mallet  force  could  not  be  brought  to  bear  upon 
this  class  of  cavities;  but  these  instruments  held  in  position,  will 
give  direct  forward  force,  and  can  be  worked  across  the  mouth  with 
great  satisfaction.  They  also  apply  upon  the  superior  bicuspids 
and  molars  equally  well. 

A^os.  28  and  29,  Eight  and  Left  Treble-curved  Molar  Modelers, 
apply  at  the  posterior  cervical  walls  of  the  inferior  bicuspids  and 
molars,  and  serve  to  model  up  all  the  posterior  surface  of  the 
fillings,  enabling  the  operator  to  give  most  direct  forward  force. 
They  reach  a  point  that  no  other  instruments  will.  Posterior  lin- 
gual cusps  can  be  reached  with  these  instruments,  and  condensed 
upon  their  posterior  and  lingual  angles, — a  point  that  has  been 
hard  to  reach.  They  also  work  across  the  mouth  with  great  advan- 
tage, and  can  be  applied  to  the  superior  bicuspids  and  molars  as 
well.     For  applying  the  instrument  to  the  right  inferior  molar. 


DR.    palmer's    plugging    INSTRUMENTS.  493 

stand  at  the  back  of  and  above  the  patient,  holding  the  instrument 
firmly  in  the  whole  hand,  letting  the  thumb  rest  upon  the  shaft  of 
the  instrument,  and  next  the  cheek,  and  give  tense  directing  force. 
For  the  left,  stand  upon  the  left  side,  grasping  the  instrument 
firmly  with  the  whole  hand,  letting  the  fingers  go  next  the  cheek, 
and  the  thumb  firm  against  the  shaft,  and  give  tense  directing  force. 

No.  30,  Modeling  Mallet  Burnisher,  has  a  combination  of  work- 
ing faces.  Held  at  an  angle  upon  one  of  its  sloping  faces,  it  can  be 
made  to  glide  along,  and  lay  additional  pieces  of  gold,  if  desired ; 
or,  turned  more  upon  its  point,  will  follow  fine  lines  in  the  modeling 
of  cusps  and  fissures.  It  will  reach  the  posterior  surfaces  of  the 
bicuspids  and  molars,  and  can  be  used  for  the  last  hand  burnishing 
of  fillings,  if  desired.  Used  with  the  mallet,  must  be  grasped 
firmly  in  the  whole  hand,  and  given  directing  force. 

A  word  or  two  in  reference  to  thu  finish.  The  instruments  are 
purposely  finished  bright  and  polished  throughout;  because  in  a 
long  course  of  careful  practical  experiments,  I  have  found  that 
finished  in  this  way  they  keep  better,  and  are  more  pleasing  to  the 
eye.  After  the  brilliancy  of  the  first  finish  is  worn  ofi",  they  will 
assume  a  certain  dull,  silvery  surface,  which  makes  them  pleasant 
to  hold,  and  they  are  always  clean  and  presentable. 

The  Cases  are  made  from  a  new  design  of  my  own,  suited  to 
practice. 

They  contain  the  plugging  instruments,  four  pieces  of  forceps,  a 
foil  carrier,  and  dressing  needle ;  all  of  which  are  new,  and  especi- 
ally designed  and  adapted  to  the  mouth  by  myself. 

Nos.  1  and  No.  2  are  punches  for  the  rubber  dam,  and  are  so 
formed  that  they  can  be  applied  to  put  in  new  holes  after  the  dam 
is  adjusted,  and  thus  enable  the  operator  to  extend  the  dam  with- 
out the  necessity  of  removing  it  from  the  mouth — a  most  desirable 
feature  in  its  use. 

The  Wedge  Cutter  is  so  formed  and  curved  that  it  can  be  made 
to  reach  any  point  desired,  enabling  the  operator  to  cut  off  a  wedge 
far  back  in  the  mouth,  or  nip  a  point  along  the  lingual  surfaces  of 
the  teeth. 

The  W'dge  Forceps  is  an  entirely  new  instrument,  in  size  and 
form,  pleasant  to  the  hand  and  eye.     Its  curve  enables  the  operator 


494  APPENDIX. 

to  pass  it  far  back  in  the  mouth,  to  reach  any  point  desired,  and 
insert  or  withdraw  a  wedge,  pull  off  a  dipt  ligature,  or  hold  a  piece 
of  wood  for  porte  polish,  to  apply  upon  the  lingual  surfaces,  par- 
ticularly the  inferior  incisors.  Must  not  be  used  for  handling 
engine  bits. 

The  Foil  Carrier  is  to  be  used  for  picking  up  the  gold,  holding 
it  in  the  flame  of  the  spirit  lamp,  and  carrying  it  to  the  mouth. 
May  be  used  also  for  introducing  and  removing  dressings.  Must 
be  held  between  the  thumb  and  forefinger,  letting  the  top  of  the 
instrument  pass  over  the  back  of  the  hand,  and  not  placing  the 
hand  on  the  top  of  the  instrument.  The  points  are  the  most 
advantageously  curved  for  its  application  to  all  parts  of  the  mouth. 
This  foil  carrier  is  designed  to  be  useful  in  a  certain  mode  of  prac- 
tice which  I  wish  to  recommend,  and  that  is :  during  the  operation 
of  filling,  not  to  lay  down  the  foil  carrier,  but  place  it  between  the 
lips.  In  this  way  it  is  always  ready,  and  no  time  is  lost  in  hunting 
for  it.  I  must  not  forget  to  caution  against  the  danger  of  letting 
it  fall  in  the  face  of  the  patient,  and  hope  that  all  are  thoughtful 
enough  to  be  upon  their  guard  in  that  respect.  I  dwell  a  little 
upon  this  instrument  because  it  is  one  of  the  most  important  and 
first  looked-for  when  we  are  ready  to  fill.  It  is  not  intended  to  be 
used  as  a  plugger,  and  is  made  purposely  light,  and  not  with  too 
stifi"  a  spring,  so  that  it  can  be  held  as  above  described,  without  an 
unpleasant  strain  upon  the  lips,  and  yet  tempered  and  stiflF  enough 
through  the  body  and  points  not  to  bend  when  used  to  insert  or 
remove  a  dressing. 

Dressing  Needh. — Although  this  instrument  has  its  more  ex- 
tended range  of  usefulness,  it  is  so  inseparable  from  the  operation 
of  filling,  that  I  consider  the  case  would  be  incomplete  without  it. 

In  the  last  preparation  of  a  cavity,  particularly  where  there  are 
sensitive  surfaces,  it  is  desirable  to  give  a  dressing  before  introducing 
a  filling.     This  instrument  is  the  one  best  suited  to  the  purpose. 

In  case  of  dressing  over  exposed  nerves,  to  allay  pain,  the 
rounded  top  will  be  useful  to  fix  the  cotton  smoothly  in  position. 

In  conclusion,  let  me  say,  that  the  instruments  are  designed  to  be 
graceful  in  form,  artistic  in  finish,  proportionate  in  size  and  length 
— each  one  having  its  particular  use — together  forming  one  syste- 
matic whole. 


MALLETS.  495 


SECTION  C— MALLETS. 

The  Electro-Magnetic  Mallet. — Electro-magnetism  has, 
within  the  last  three  or  four  years,  been  applied  and  used  as  a 
motive  power  for  the  automatic  plugger. 

The  plugging  instrument  operated  by  this  force,  though  not  in 
general  use  (and  perhaps  never  will  be),  yet  by  some  it  is  prized 
very  highly,  and  used  with  great  efficiency. 

To  those  unacquainted  with  electric  force,  and  the  appliances 
through  which  to  make  it  available,  this  instrument  will  appear 
complicated  and  difficult  to  keep  in  proper  condition,  but  to  those 
familiar  with  it,  it  is  easily  controlled  and  mananed. 

The  following  extracts  from  a  paper  on  the  electro-magnetic 
mallet,  by  Dr.  Louis  Jack,  is  so  directly  to  the  point  that  we  can 
hardly  do  better  than  present  them  here. 

He  says,  "  The  first  attempt  to  take  advantage  of  electro-mag- 
netism for  this  purpose,  it  would  appear,  must  be  credited  to  Mr. 
G.  F.  Green,  who  first  produced,  according  to  his  own  statements, 
an  instrument  in  which  he  made  use  of  the  power  which  a  heliacal 
coil  has  to  draw  within  it  towards  its  middle  a  piece  of  iron,  sus- 
pended, or  temporarily  held  at  its  either  end. 

"  At  each  influx  of  the  electrical  current  the  suspended  iron 
would  fly  to  the  centre  with  quickness,  to  be  stopped  by  the  plugger 
end,  arranged  to  meet  it  at  that  point;  at  this  moment  the  current 
was  shut  off,  when  the  mallet  would  fly  back,  under  the  force  of  a 
spring,  only  to  return  again  by  the  recurrent  opening  of  the 
circuit, 

"The  experiments  with  this  class  of  electric  pluggers  have 
proven  unsucessful." 

Mr.  Gret^n  made  other  experiments  which  were  equally  unsuc- 
cessful. 

Dr.  Jack  further  remarks  : — "  Entirely  independent  of  any 
knowledge  of  what  Mr.  Greene  had  been  doing  in  this  direction, 
Dr.  Bonwill,  after  watching  the  working  of  the  armature  in  the 
magnetic  telegraph,  conceived,  with  true  inventive  talent,  the  idea 
of  utilizing  this  arrangement,  and  with  the  necessary  modifications 


496  APPENDIX. 

and  adaptations  to  employ  the  force  which  impacts  the  style  upon 
the  paper,  at  the  delivery  of  the  same  quick  blows  upon  the  plug- 
ging point.  He  therefore  attached  his  armature  by  its  middle  upon 
a  point  at  a  distance  relatively  flxr  from  the  electro-magnet,  making 
the  armature  act  as  a  mallet.  Thus  was  secured  a  light  and  intense 
blow,  and  as  the  armature  moved  through  a  small  distance,  gained 
the  additional  quality  of  rapidity ;  a  combination  of  qualities  of 
the  highest  importance  rendered  his  instrument  practically  efficient. 

"  Dr.  Bonwill  has  from  time  to  time  improved  his  first  instru- 
ment, until  we  now  have  from  his  hands  one  which  has  proven 
satisfactory  in  most  respects.  To  him,  therefore,  we  are  indebted 
for  the  first  useful  electro-magnetic  mallet." 

After  Dr.  Bonwill  had  arrived  at  a  point  in  the  construction  of 
this  instrument  beyond  which  he  concluded  not  to  go,  Dr.  Jack 
made  some  modifications  of  the  instrument,  the  purport  of  which 
may  be  inferred  from  the  following  extracts : 

"  The  objects  of  this  invention  are  to  render  the  movements 
simpler  and  more  direct  than  has  heretofore  been  done,  with  the 
ends  in  view  to  produce  a  sharp  and  decided  impact ;  to  lessen  the 
sounds  of  the  movement  at  both  the  time  of  the  impact  and  recoil, 
and  to  produce  a  lighter,  cheaper,  more  convenient  and  agreeable 
instrument. 

"  The  principal  feature  of  this  invention  consists  in  the  form 
given  to  the  electro-magnet.  The  core  is  made  the  segment  of  a 
cylinder,  so  that  when  the  helices  are  formed  and  placed  together, 
they  produce  a  more  or  less  cylindrical  body,  leaving  between  them, 
at  the  central  part,  a  circular  aperture  for  the  reception  of  a  small 
cylinder. 

"  This  cylinder  receives  a  plugger,  which  imparts  the  force 
of  the  armature  upon  the  plugger,  and  at  the  same  time  permits 
freedom  of  movement  and  gives  direction  to  the  armature. 

"  There  are  other  improvements  depending  upon  this  one,  and 
connected  therewith,  viz. : 

"  The  form  of  the  armature  and  its  connected  parts. 

"  The  form  and  arrangement  of  the  circuit  closer. 

"  The  form  and  arrangement  of  the  interrupter. 

"  The  device  employed  to  deaden  the  recoil. 


MALLETS.  497 

"  The  means  of  securing  the  adjustments  of  the  instruments.  .  .  . 

"  The  best  results,  and  the  least  discomfort  of  the  patient  are 
secured  by  careful  attention  to  the  adjustments, 

"  It  should  be  noticed  in  this  connection  that  the  greatest 
economy  will  be  found  in  having  the  batteries  in  clean  condition, 
replenished  to  good  strength,  and  the  zinc  plates  kept  freely  amal- 
gamated." 

In  a  paper  on  the  electro-magnetic  mallet,  by  Dr.  E.  T.  Darby, 
July,  1875,  in  speaking  of  the  advantages  which  the  electric  mallet 
possesses  over  all  other  instruments  intended  for  the  purpose  of 
consolidating  gold  in  the  operation  of  filling  teeth,  he  says :  "  It  is 
purely  automatic  in  its  action. 

*'  Its  power  or  force  is  entirely  distinct  from  anything  physical 
or  individual,  except  the  will  of  the  operator,  and  the  touch  of  his 
educated  finger. 

"  No  more  physical  force  is  required  to  manage  it  than  would 
guide  a  pen  or  hold  a  pencil. 

"  The  dentist  may  stand,  or  sit  in  his  chair,  hour  after  hour,  and 
fell  no  greater  fatigue  than  would  naturally  result  from  restrained 
position,  or  concentrated  thought. 

"  Nor  is  it  a  labor-saving  instrument  only ;  it  is  a  time-saving 
invention  also. 

"  The  length  of  time  required  to  thoroughly  pack  the  gold  in 
most  cavities  is  lessened  at  least  one-half  by  the  aid  of  the  electric 
mallet. 

"  Nor  is  it  a  time-saving  instrument  only,  it  is  a  pain-saving  ap- 
pliance as  well. 

"  The  blow  produced  by  the  electric  mallet  is  sharp  and  quick, 
and  does  not  jar  the  touth  like  the  hand  mallet,  or  some  other 
automatics. 

"  The  operator  must  be  skilled  in  its  use,  otherwise  he  will  fail 
to  accomplish  the  best  results." 

The  paragraphs  above  quoted  from  the  two  papers  referred  to  on 
the  electric  mallet,  indicate  about  an  average  estimate  entertained 
by  those  who  have  become  thoroughly  familiar  with  its  use. 

The  following  illustration  shows  the  present  improved  form  of 
the  instrument. 


498 


APPENDIX. 

Fig.  126. 


Description  of  Electro-magnetic  Mallet  of  Dr.  Bonicill. — No.  1, 
%  size.  E.  the  horse  shoe  maj^net.  M,  the  brass  frame  fixed 
firmly  to  magnet  at  the  top,  and  holding  the  arm  0,  at  L,  on  two 
pivoted  screws.  R,  hard  rubber  handle,  with  tool  P  running 
through  it  and  extending  as  far  to  the  right  under  the  hammer  as 
A.  K,  slide  key,  upon  which  right  index  finger  rests  for  making 
the  circuit,  and  causing  the  blows  in  rapid  succession  by  simply 
pushing  slide  or  key  forward.  F,  the  ring  through  which  right 
index  finger  passes  and  supports  the  mallet  and  prevents  falling. 
Thumb  rests  on  tool  just  below  K,  and  revolves  tool  in  any  direc- 
tion. J,  an  eccentric  screw  head  to  regulate  the  slide  K,  to  make 
it  of  very  delicate  touch.  L,  posts  into  which  the  flexible  wires 
from  battery  go.  N,  spiral  spring  inside  for  throwing  the  armature 
0  back  against  the  check  screw  head  C,  which  head  also  opens  or 
closes  to  control  the  distance  the  hammer  travels.  H,  screw  to 
regulate  strength  of  spiral  spring  in  N.  D,  B  and  A,  the  auto- 
matic brake,  which  controls  the  number  of  blows  of  hammer,  li, 
screw  head  for  raising  or  lowering  to  permit  the  tool  to  always  keep 
the  right  distance  to  be  struck  by  armature,  or  hammer,  flakes 
5U0  to  3000  blows  a  minute.     Weight,  eight  ounces,  avoirdupois. 

Mallet  No.  2. — This  is  exact  size  of  magnets  and  the  frame.  It 
weighs  but  (Jl  ounces  avoirdupois. 

H,  horse  shoe  magnets,  very  compact.  L,  the  armature  without 
frame  or  hammer  thereon.  A.  screw  to  regulate  the  spring  of  the 
circuit  braker.  B,  posts  for  attaching  flexible  wire  from  battery. 
C,  automatic  brake,  which   is  struck  by  poiut  of  spring   F.  and  is 


MALLETS. 


499 


always  pressiDg  hard  thereon.     E,  screw  regulator  of  tool,  peruiit- 
tiug  it  to  let  head  of  tool  project  enough  to  move  forward  about 


one-fiftieth  of  an  inch  when  struck  by  M  on  the  end  of  brake 
C.     G,  handle  of  hard  rubber. 

This  is  now  as  complete  as  can  well  be  made.  The  first  instru- 
ment weighed  one  pound.  This  last  is  all  we  could  ask  in  size 
and  weight,  as  well  as  shape.  The  handle  and  the  hammer  on 
the  armature  are  not  shown  in  the  cut  of  this  mallet,  nor  is  the  ring. 

They  are  both  run  by  three  cups  of  smallest  size  Bunseu  Coke 
Battery;  it  costs  about  15  cents  a  week  to  charge  them.  These  are 
the  only  practical  electro-magnetic  mallets  now  in  use.  As  to 
saving  of  time,  it  has  been  claimed  by  the  inventor  that  he  has 
packed  one-quarter  ounce  foil  in  one  hour  fifteen  minutes.  It  will 
save  three  out  of  four  hours,  and  nearly  all  the  labor. 


Automatic  Plugger  for  Engine. — This  instrun)ont  is  the 
invention  of  Dr.  T.  L.  Buckingham,  and,  as  the  caption  indicates, 
is  operated  by  the  dental  engine.  Those  who  have  used  the  in- 
strument and  are  most  familiar  with  it  claim  that  it  possesses  every 
available  quality  for  such  an  appliance.  The  blow  is  given  by  a 
spring,  and  is  entirely  under  the  control  of  the  operator;  it  is 
regulated  by  a  set  screw  on  the  head  and  a  movable  collar  on  the 
hand-piece.  The  latter  can  be  moved  at  will  during  the  operation 
of  the  instrument,  regulating  the  stroke  from  the  strongest  required 


600  APPENDIX. 

to  the  lightest  appreciable  touch  ;  or  the  blows  can  be  suspended 
altogether  and  the  instrument  used  as  a  hand  plugger,  and  that, 
too,  without  stopping  the  engine. 

The  requirements  of  delicate  operations  needing  special  and  pre- 
cise manipulation,  are  well  met  by  the  skillful  use  of  this  instrument. 

The  bit  holder  is  movable,  and  is  drawn  back  after  each  blow 
by  a  small  spiral  spring  attachment. 

The  instrument  as  ordinarily  used  gives  about  eighteen  hundred 
blows  per  minute,  but  the  number  can  be  greatly  reduced  by  a 
simple  change  in  the  machinery,  which  can  be  effected  in  a  few 
moments,  and  thus  the  blows  reduced  to  less  than  one  hundred 
per  minute. 

The  points  used  in  this  are  such  as  are  in  common  use  with 
automatic  mallets. 

A  ring  accompanies  this  instrument,  which  being  attached  to  it 
will  aid  the  operator  in  holding  and  directing  it  while  operating. 
It  is  represented  by  the  following  cut  (Fig.  128). 

Hyde's  Pneumatic  Plugger. — This  instrument  was  devised 
and  introduced  to  the  profession  about  1870.  It  consists  of  a 
small  cast  iron  frame,  to  which  is  attached  a  small  cylinder,  which 
with  its  piston  serves  as  an  air  pump  ;  this  is  operated  by  fly  and 
drive  wheels  which  are  arranged  in  the  frame  and  operated  by  the 
foot. 

To  the  cylinder  is  attached  a  rubber  tube  about  seven  feet  in 
length ;  to  this  is  attached  the  hand  piece,  within  which  a  plunger 
plays;  when  in  motion  this  communicates  its  impulse  to  the 
plugger. 

As  the  plugger  in  the  cylinder  is  driven  to  and  fro,  the  hammer 
in  the  hand  piece  responds,  expending  its  force  upon  the  socket 
piece  that  holds  the  plugging  point. 

The  blow  is  direct  and  elastic,  as  the  piston  or  hammer  is  with- 
drawn the  moment  the  blow  is  given. 

The  rapidity  of  stroke,  as  well  a.s  the  force,  is  completely  under 
the  control  of  the  operator. 

This  instrument,  in  the  hands  of  those  who  have  become  familiar 
with  it,  is  very  efficient  and  easily  operated. 


501 


502  APPENDIX. 

A  modification  of  this  instrument  has  been  made,  which  consists 
of  substituting  a  rubber  ball,  about  three  inches  in  diameter,  for 
the  frame,  wheels  and  cylinder ;  and  the  operation  is  effected  by 
working  the  foot  upon  the  ball.  This  certainly  has  the  advantage 
of  being  much  more  simple. 


SECTION  D.— MATRICES  FOR  PROXIMAL  FILLINGS. 

To  Dr.  Louis  Jack  belongs  the  honor  of  devising  and  putting 
into  practical  form  the  matrices  as  aids  in  filling  teeth. 

His  description  of  these  appliances,  and  the  manner  of  using 
them,  is  so  concise  and  complete,  that  we  have,  with  his  consent, 
transfen-ed  it  almost  wholly  to  these  pages.  By  a  careful  study 
of  the  directions  here  given,  almost  any  one  of  good  manipulative 
ability  will  be  able  to  use  them  with  good  results.  T. 

"  The  first  step,  in  case  the  teeth  are  in  close  contact,  is  to  sepa- 
rate them,  either  by  pressure,  or,  as  in  so  extensive  caries  as  is 
under  consideration,  by  a  parallel-sided  file ;  and  from  this  slight 
separation  rapidly  and  freely  open  by  cutting  down  the  enamel  at 
the  middle  of  the  space,  afterwards  increasing  somewhat  freely 
with  the  chisel  the  inner  portion  of  the  opening.  Another  plan  I 
sometimes  pursue,  where  no  fracture  of  the  masticating  plate  has 
occurred,  is  to  pass  a  small  five-sided  drill  until  it  fails  to  meet 
with  resistance,  increasing  by  a  larger  drill ;  and  from  these  two 
half  circles  I  cut  in  either  direction  with  suitable  chisels  by  care- 
fully splitting  down  the  enamel, — first  the  masticating  portion, — 
and  continuing  until  a  free  space  is  secured  on  the  inner  side ;  then 
more  carefully  opening  towards  the  buccal  division,  until  a  slight 
space  is  made  at  this  point.  The  file  may  be  used  at  this  stage  to 
further  open  the  space,  and  in  bringing  the  surfaces  into  proper 
shape  and  smoothness.  When  the  cavities  are  so  large  as  is  as- 
sumed above,  there  will  usually  be  found  so  much  disorganization 
of  the  enamel  as  to  render  necessary  so  much  cutting  to  procure  a 


MATRICES    FOR    PROXIMAL   FILLINGS.  503 

healthy  surface  as  will  open  a  space  abundantly  large  for  the  sub- 
sequent work.  If  more  is  needed,  it  is  secured  by  wedging;  in 
any  case  a  separation  as  large  at  the  lower  part  as  a  No.  7  Froid 
file,  and  at  the  cervical  part  as  a  No.  3,  is  easily  secured.  The 
buccal  space  should  be  but  slightly  wedge-shaped,  and  somewhat 
smaller  than  the  palatal,  for  reasons  which  will  appear  in  the 
proper  place. 

After  removing  the  softer  caries,  the  walls  of  the  cavity  are  pre- 
pared for  the  reception  of  the  filling;  the  overhanging  masticating 
plate  being  first  cut  away  in  a  circular  form  on  a  line  with  the 
bottom  or  pulp  wall,  so  that  by  direct  approach  every  part  of  the 
cavity  is  accessible  to  slightly  curved  or  even  straight  instruments. 
This  opens  the  whole  cavity  to  view.  The  instrument  best  adapted 
for  this  purpose  is  the  gouge-shaped  chisel,  which  cuts  with  ex- 
ceeding keenness,  and  produces  the  form  desired  at  this  part. 
The  removal  of  this  portion  of  the  enamel  is  an  important  and  iu- 
dispLMisable  step  in  the  improvement  I  am  pursuing.  It  is  prac- 
ticed by  the  better  operators  to  a  somewhat  less  degree,  and  is  in 
many  ciises  an  advantage  to  the  organ.  No  other  argument  to  de- 
fend this  course  may  be  used  than  that  in  these  fillings,  so  difficult 
of  execution,  everything  subservient  to  better  performance  must 
be  followed  out  which  is  not  injurious  to  the  strength  and  preser- 
vation of  the  organ.  It  will  often  prove  true  here,  as  elsewhere  in 
surgery,  that  something  must  be  taken  to  save  the  remainder. 

The  cervical  wall  is  now  cut  at  a  right  angle  to  the  proximal 
surface,  taking  care  to  remove  from  the  surface  of  the  tooth  beneath 
the  gum  any  half-decomposed  enamel  which  may  be  present  at  this 
part.     No  retaining  groove  or  pits  are  needed  on  this  wall. 

The  buccal  and  palatal  walls  are  next  smoothly  cut,  and  on  the 
side  of  each,  where  they  have  sufficient  strength,  a  shallow,  round- 
bottomed  groove  is  made  the  whole  length,  and  terminating  at  the 
very  surface  of  the  masticathir/  j^^cte  of  enamel.  The  outer  retain- 
ing groove  should  be  near  the  margin,  to  avoid  any  approach  to  the 
pulp  ;  the  inner  one  should  be  nearer  the  bottom  of  the  cavity, 
so  that,  in  the  subsequent  cutting  away  of  a  portion  of  the  palatal 
wall  in  the  finishing  process,  the  hold  of  the  gold  may  not  be 
obliterated.     The  instruments  best  adapted  for  this  grooving  are 


504  APPENDIX. 

made  by  filing  a  straight  point  quite  round  and  small,  then  bending 
at  a  suitable  angle,  and  shaping  so  as  to  have  the  edge  at  the  inner 
side  of  the  curve.  Instruments  of  this  form  are  better  adapted  for 
cutting  the  hard  dentine  and  enamel  than  any  others,  for  the 
reasons  that  they  may  be  made  harder  than  usual  without  danger 
of  breakage ;  they  cut  with  more  keenness,  do  not  chatter,  leave 
the  surface  without  sharp  lines,  and  in  grooving  each  cut  follows 
in  the  last  with  certainty.  They  are  directly  reverse  in  form  to 
the  hoes  and  excavators  in  general  use 

The  pulp  wall  of  the  cavity  is  not  altered  in  the  form  it  presents 
after  the  removal  of  the  caries. 

The  next  and  very  important  step  is  to  remove  the  sharp  corners 
of  the  mouth  of  the  cavity  ;  and  at  every  part  well  polish  it  with 
pumice-stone ;  this  facilitates  the  passage  of  the  gold  over  the  sur- 
face and  the  perfect  contact  of  the  foil  with  every  part.  This 
polishing  is  rapidly  done  by  rotating  a  piece  of  boxwood  armed 
with  pulverized  pumice. 

Selection  is  now  made  of  one  of  the  appliances  figured  below, 
which  are  intended  to  give  form  to  the  outer  surface  of  the  filling, 
and  are  called  matrices  for  this  reason.  These  little  affairs  are 
made  of  a  variety  of  shapes,  sizes,  and  thickness.  They  are  formed 
of  slightly  wedge-shaped  pieces  of  steel,  and  are,  as 
the  cut  designates,  hollowed  out  at  their  thicker  edge, 
which  depression  terminates  at  the  thinner  edge.  At 
the  part  of  the  depression  designed  to  give  shape  to 
the  buccal  edge  of  the  tilling  the  cut  is  generally  abrupt  and  deep ; 
at  the  inner  portion  it  is  more  shallow  and  more  inclined.  It  will 
be  observed  that  the  depression  widens  as  it  passes  toward  the 
thinner  edge  to  follow  the  usual  form  of  proximal  cavities.*  The 
lower  and  thin  edge  is  rounded,  to  outline  the  curved  margin  of 
the  cervical  wall,  and  to  effect  pressure  upon  either  the  gum  or  the 
appliances  used  to  stop  the  escape  of  mucus  and  blood  from  this 
tissue. 

The  plane  parts  of  the  face  are  file-cut  or  coarsely  draw-filed. 
The  reverse  side,  represented  in  Fig.  130,  and  which  for  conveni- 

*  In  Fig.  129  the  bounJary  of  the  riglit  end  of  the  depression  should  be 
similar  to  the  other  end. 


I 


MATRICES    FOR    PROXIMAL    FILLINGS.  505 

ence  of  description  is  divided  into  three  sections,  is  in  most  cases 

plane  and  smooth,  excepting  at  the  section 

c,  which  is  file-cut.     It  is  often  necessary  '^' 

to  have  this  side  in  two  surfaces ;  one  sec- 

P- 
tion,  a,  parallel  with  the  plane  parts  of  the 

face,  and  from  this  point  inclining  to  a  thin 

edge.     A  very  desirable  form  is  to  have  section  c  bent  backwards 
to  follow  the  incline  of  the  proximate  tooth  beneath  the  gum.     At 
each  end  a  square-cut  is  made  to  fit  the  plier  ends  represented  at 
Fig.  131.     After  being  formed,  they  are  protected  from  oxidation, 
heated  to  redness,  plunged  in  the  cold  bath,  and  temper 
drawn  to  near  blueness ;  after  polishing  the  depression,      ^' 
they  will  be   ready  for  use.     Quite  a  number  of  pairs     ^   ftl 
are  necessary  to  meet  the  requii'ements  of  the  differing  " 

cases;  but  for  the  ordinary-sized  simple  proximal  cavities,  a  dozen 
pairs  varying  in  width,  in  thickness,  and  in  size  of  depression,  are 
all  that  I  have  found  necessary.  Fig.  129  represents  the  largest 
size  required,  those  in  most  use  not  being  more  than  from  one- 
half  to  two-thirds  this  width  and  thickness.  The  character  of 
these  modifications  will  depend  somewhat  upon  the  desired  end, 
since  either  a  flat,  contour,  or  excessively  convex  surface  may  be 
produced  at  the  pleasure  of  the  operator,  or  to  suit  the  needs  of 
the  individual  operation,  by  varying  the  form  and  depth  of  the 
depression.  It  is  also  occasionally  necessary  to  have  a  matrix  of 
unusual  form  to  meet  special  cases,  where  the  space  is  extremely 
great,  or  where,  from  the  fracture  of  the  outer  plate  of  enamel,  a 
steel  one  will  not  remain  in  position  ;  for  this  purpose  I  have  found 
hard  boxwood  to  answer  quite  well.  Silver  also,  in  such  cases,  will 
occasionally  be  fou<id  useful.  I  sometimes  take  an  impression  of 
the  immediate  part  to  assist  me  in  the  fabrication  of  a  suitable  ap- 
pliance. I  have  also  made  double-faced  ones,  which  are  so  formed 
as  on  one  adjustment  to  allow  both  cavities  to  be  filled.  For  isolated 
teeth  having  large  posterior  cavities,  a  ring  of  silver  may  be  used, 
carrying  out  the  same  principle  in  forming  the  portion  which 
bounds  the  cavity.     I  have  used  the  same  plan  in  buccal  cavities. 

The  selected  matrix  should,   at  the  convex   edge,  be  a  little 
thinner  than  the  space  between  the  teeth  at  their  closest  part  by 


506  APPENDIX. 

the  gum  J  it  should  pass  above  the  edge  of  the  cervical  wall,  and 
should  conform  at  this  part  to  the  contour  of  the  tooth ;  the  lower 
and  thicker  edge  should  reach  nearly  to  the  masticating  surface, 
and  this  edge  should  not  entirely  fill  the  lower  part  of  the  space; 
above  all,  the  depression  at  every  part  of  its  border  should  extend 
slightly  beyond  the  edge  of  the  cavity. 

After  having  secured  the  cervical  part  of  the  case  from  the  en- 
croachment of  moisture — by  means  of  the  rubber  dam,  or,  when 
this  is  not  applicable,  wedges  of  wood,  little  rings  of  india-rubber,  the 
string  dam,  short  pieces  of  waxed  twine,  of  such  size  as  to  remain 
firmly  in  place  when  drawn  between  the  teeth,  the  application  of 
dilute  chloride  of  zinc,  etc.,  or  a  combination  of  two  or  more  of  these 
means — the  matrix  is  taken  up  in  the  pliers  (Fig.  131),  and  pushed 
upward  until  it  presses  upon  the  gum  or  the  appliances,  and  until 
it  impinges  tightly  between  the  teeth.  It  is  now  wedged  firmly 
against  the  tooth  to  be  operated  upon  with  little  boxwood  wedges ; 
these  secure  it  in  place  during  the  packing.  It  is  well  usually  to 
insert  two  wedges,  one  from  the  buccal  side  between  the  teeth  near 
the  margin  of  the  gums,  and  one  from  the  palatine  or  lingual  side 
nearer  the  masticating  surface  of  the  teeth  than  the  margin  of  the 
gum ;  thus  the  matrix  will  be  firmly  keyed  to  its  proper  position. 
When  the  matrix  passes  up  to  the  proper  point,  the  wedging  towards 
the  cavity  throws  the  lower  edge  against  and  somewhat  beneath  the 
projecting  swell  of  enamel  of  the  neighboring  tooth,  which  adds  to 
the  security.  However  tightly  the  matrix  may  fit  between  the 
teeth,  it  will  not  frequently  retain  its  fixedness  unless  securely 
wedged.  Boxwood  answers  for  this  purpose  better  than  any  sub- 
stance I  have  employed,  for  the  reason  that  it  is  so  hard  as  to  be 
unyielding,  and  on  this  account  also  does  not  require  to  be  more 
than  pushed  into  the  space.  The  wedges  should  be  made  to  con- 
form in  size  and  shape  to  the  space  they  are  intended  to  occupy, 
in  order  that  they  may  the  more  firmly  retain  their  position  when 
inserted.  Moistening  them  with  a  solution  of  gum  sandarac  or 
mastic  adds  much  to  their  security  in  position  after  they  are  intro- 
duced.    The  pliers  (Fig.  131)  are  adapted  to  their  introduction. 

In  case  the  adjoining  teeth  are  not  in  contact,  it  is  always  neces- 
sary to  introduce  a  wedge  between  them,  to  give  greater  firmness 


I 


MATRICES    FOR    PROXIMAL    FILLINGS.  507 

to  the  teeth  and  less  discomfort  to  the  patient.  In  all  large  cavities 
I  fix  the  matrix  previous  to  introducing  the  napkins.  Where  the 
rubber  dam  is  required,  it  precedes  this  appliance,  which  may  aid 
in  keeping  the  rubber  in  place. 

For  the  small  cases,  the  drying  is  done  first,  the  napkins  applied, 
and  a  hard  rope  of  bibulous  paper  is  passed  against  the  gum,  fol- 
lowed by  the  matrix.  Fig.  132  represents  the  appearance  of  the 
parts  at  this  stage,  except  the  wedges,  which  are 
not  shown.     When  the  cavity  is  now  examined,  "' 

it  will  be  found  to  present  an  open  mouth,  formed 
by  its  curved  lower  edge  of  enamel,  and  by  the 
boundary  of  the  matrix,  through  which  funnel- 
shaped  opening  every  part  of  the  space  is  easily 
seen  and  directly  touched.  The  case  is  now  ready  for  the  recep- 
tion of  gold. 

I  use  for  the  upper  half  or  more  of  the  filling,  ribbons  of 
Nos.  4,  5,  or  6,  of  non-cohesive  gold,  not  annealed.  These  ribbons 
are  made  of  one-fourth  to  whole  sheets  of  foil,  depending  on  the 
size  of  the  space,  and  then  folded  into  blocks,  varied  in  length  by 
the  requirements  of  the  case.  For  the  lower  third  I  prefer  rolled 
gold  of  No.  20  to  30,  of  the  most  adhesive  character,  and  annealed. 
I  also  use  for  this  part  in  many  cases  '•  Eureka  gold  filling,"  No. 
15,  with  the  greatest  advantage,  taking  up  one  or  more  of  the 
shreds,  and  working  them  in  wherever  needed.  The  first  block  or 
mat  is  passed  up  toward  the  outer  border,  until  it  reaches  the 
cervical  wall,  when  the  lower  end  is  pushed  into  place,  and  fastened 
by  pressure  into  the  upper  part  of  the  retaining  groove.  The 
second  piece  is  secured  in  the  same  manner  in  the  inner  or  palatal 
groove ;  a  further  piece  is  forced  between  the  two,  and  directly 
against  the  cervical  wall.  When  a  sufficiency  of  gold  is  placed 
upon  these  parts  to  save  the  tooth  from  contact  of  the  points, 
the  gold  is  securely  malleted  against  the  walls  at  all  points,  pay- 
ing particular  attention  to  the  junction  of  the  tooth  with  the 
matrix.  In  this  way  I  proceed,  successively  introducing  and 
malleting,  until  the  cavity  is  two-thirds  filled,  not  hastening  further 
at  any  point,  unless  the  assurance  is  reached  that  the  gold  is  per 
fectly  consolidated.     At  this  point  I  commence  and  continue  the 


508  APPENDIX. 

eniploymeut  of  heavy  gold,  the  first  pieces  of  which  should  be  well 
fixed  in  the  gold  previously  introduced  at  the  parts  over  the  re- 
taining grooves,  and  also  worked  well  into  the  foundation.  It  is 
now  a  simple  matter  to  fill  up  the  remainder  with  quickness. 

In  case  there  should  happen  to  be  an  encroachment  by  moisture 
at  near  the  close  of  the  packing,  the  gold  may  be  made  smooth  on 
the  exposed  surface,  dried,  and  the  latter  part  inserted,  with  all  the 
characteristics  of  a  separated  filling.  The  form  of  the  last  third  is 
such  that,  if  inserted  with  dryness,  no  portion  can  escape.  The 
matrix  should  now  be  removed. 

It  will  be  found,  if  the  selection  and  adjustment  of  the  matrix 
has  been  correct,  that  very  little  filing  and  cutting  down  of  the  plug 
will  be  required,  and,  in  case  the  packing  has  been  carefully  per- 
formed, that  the  gold  will  be  solidly  condensed  at  every  part.  It 
will  also  be  noticed  that,  while  the  gold  is  solid,  it  will  not  have 
become  hardened  in  temper  on  the  proximal  surface,  but  yields 
laterally  under  the  burnisher,  not  unlike  lead  or  tin. 

I  must  at  this  point  call  attention  to  the  importance  of  the  adap- 
tation of  the  filling  material  to  the  cervical  wall,  which  it  requires 
no  words  to  show  will  be  secured  by  this  method.  There  can 
hardly  be  a  question  that  the  general  failure  of  proximal  fillings  is 
due  to  one  or  both  of  two  causes, — the  imperfect  preparation  of  the 
cavity,  and  the  want  of  solidity  and  adaptation  of  the  gold  at  this 
part.  When  the  filling  extends  to  the  gum  or  beneath  it,  and  the 
teeth  are  not  permitted  to  come  into  apposition  here,  this  portion 
of  the  tooth,  when  well  protected,  is  least  liable  to  decay^  as  this  is 
not  the  place  where  caries  usually  commences.  And  when  the  fill- 
ing reaches  to  the  cementum,  the  recurrence  of  caries  is  still  less  to 
be  apprehended,  since  it  is  a  clearly  established,  but  apparently 
overlooked,  principle  that  this  structure  is  the  least  liable  of  the 
dental  tissues  to  destruction.  It  will  be  noticed  how  seldom  failures 
occur  along  the  cervical  edge  of  gutta-percha  fillings,  even  when 
carelessly  performed.  These  considerations  have  been  forcing  many 
,  to  seek  for  better  means  of  securing  adaptation,  solidity,  and 
smoothness  at  this  part. 

The  instruments  for  introducing  the  filling  are  of  simple  forms 
and  direct  action,  but  they  should  be  in  fine  condition, — that  is. 


MATRICES    FOR    PROXIMAL    FILLINGS.  509 

the  points  should  be  well  serrated,  and  sharp.     The  only  important 
modification  needed  are  some  pairs  of  mated  pluggers,  formed  as 
at  Fig.  133,  in  which  pne  side  of  the  edge  is  considerably  longer 
than  the  other,  which  longer  side,  in  malleting,  is  con- 
stantly kept  against  the  matrix ;  this  efiects  the  greatest 
pressure  upon  the  margins,  and  secures  with  positiveness 
the  perfect  fullness  and  the  proper  consolidation  of  the 
gold  at  these  parts.     Several  sizes  and  varied  curves  of 
this  point  are  required. 

The  finishing  of  the  case  is  not  different  from  the  usual 
course  pursued.  In  my  own  practice  I  open  still  further 
the  inner  portion  of  the  space,  which  is  easily  done  with 
chisels  and  suitable  files.  The  peculiar  form  of  the 
depression  in  the  matrix  produces  a  space  which  is  considerably 
greater  on  the  inner  side,  and  which  may  be  increased  at  pleasure. 
In  many  cases,  where  the  tendency  to  caries  is  very  great,  I  chisel 
quite  freely  from  the  inner  plates  of  enamel,  doing  this  after  both 
the  adjoining  fillings  are  inserted,  cutting  down  both  gold  and 
enamel  together,  allowing  the  fillings  to  touch  only  at  the  promi- 
nent outer  part.  The  result  is  then  an  imitation  of  the  exceedingly 
oval  bicuspid,  the  immunity  from  decay  of  which  all  must  have 
seen  examples. 

Fig.  134  represents  a  transverse  section  of  two 
cases  at  a  point  immediately  above  the  grinding 
surface,  which  exhibits  the  outline  of  the  form  of 
the  cavity  and  finished  surface  of  the  gold. 

In  full  confidence,  founded  on  considerable  trial, 
I  claim  that  this  method  of  filling  large  distal-proximal  cavities 
overcomes  several  of  the  chief  difiiculties  and  deficiencies  hitherto 
experienced,  as  well  as  enables  greater  facility  of  performance,  and 
the  security  of  excellent  results." 


510  APPENDIX. 


SECTION  E.— SALICYLIC  ACID. 

This  preparation,  though  but  recently  introduced,  promises  much 
as  a  therapeutic  agent  in  dental  practice. 

The  following  quotations  from  those  who  have  given  it  attention 
and  considerable  investigation,  will  convey  some  idea  of  its  uses  and 
value. 

The  fullowiug,  from  the  Chemist  and  Druggist^  indicates  much 
a.s  to  its  properties  and  characteristics.  T. 

The  dominion  of  "  elegant  pharmacy  "  has  been  extended  ;  anti- 
septics and  deodorisers  may  no  longer  boast  of  an  exclusive  privilege 
to  be  as  disagreeable  and  abominable  as  they  please ;  an  aristocratic 
first  cousin  to  carbolic  acid  has  entered  into  trade,  and  is  rapidly 
proving  to  demonstration  the  superiority  of  "  blue  blood."  The 
advent,  commercially,  of  salicylic  acid  as  a  substitute  for  carbolic 
acid  may  well  be  regarded  as  a  great  stride  for  those  who  cultivate 
''  elegance  "  as  well  as  utility  and  efficacy,  for  the  former  substance 
appears  to  possess  a  degree  of  antiseptic  power  equal,  if  not  supe- 
rior, to  that  of  the  latter ;  and  while  carbolic  acid  possesses  a  dis- 
agreeable smell  and  other  unwholesome  properties,  salicylic  acid 
appears  as  a  crystalline  powder,  nearly  colorless,  possessing  a  very 
faint  sweet  taste,  and  almost  without  any  injurious  action  on  the 
health. 

Salicin  is  the  well-known  vegetable  principle  existing  in  variou.s 
.species  of  the  willow,  poplar,  and  other  trees  and  plants.  Salicylic 
acid  is  a  derivative  of  salicin. 

The  little  that  was  known  of  the  physiological  and  pathological 
effects  of  salicin  sufficed,  at  least,  to  draw  attention  to  those  of  its 
derivatives,  and  especially  to  salicylic  acid,  which  has  been  the 
subject  of  occasional  comment  in  the  scientific  journals  for  some 
years  past.  That  it  was  peculiarly  and  powerfully  effi3ctual  to  sus- 
pend or  entirely  prevent  fermentation  and  putrefaction  has  only 
quite  lately  been  recognized  by  the  Germans,  who  soon  found  that 
its  natural  sources,  as  above  alluded  to,  were  quite  inadequate  to 
enable  the  manufacturer  to  produce  it  in  the  quantities  and  at  the 


I 


SALICYLIC    ACID.  511 

price  that  might  s  )on  become  almost  a  necessity.  Kolbe,  Pro- 
fes:<or  of  Chemistry  at  the  University  of  Leipsic,  took  the  matter 
up,  and  recognizing  the  fact  that  phenol  or  carbolic  acid  might  be 
so  split  up  as  to  produce,  amoLg  other  substances,  salicylic  acid,  he 
devised  a  process  for  its  manufacture  which  is  now  practically  em- 
ployed at  a  clieuiical  works  at  Dresden. 

Phenate  of  sodium  is  first  prepared  by  double  decomposition  of 
phenol  of  soda,  and  well-dried  carbonic  anhydride  is  then  passed 
through  the  dry  powder  at  a  temperature  of  110  degrees  to  250 
degrees  C.  The  carbonic  anhydride  combines  directly  with  the 
metallic  derivative  of  phenol,  and  alkaline  salts  of  acids  of  a  higher 
series  are  formed  ;  among  these  salicylate  of  sodium  is  dissolved  in 
water  and  treated  with  hydrochloric  acid,  which  by  double  decom- 
position sets  free  salicylic  acid  in  small  cr3'stals.  These  crystals 
are  washed,  dissolved  in  hot  water,  and  by  recrystallization  obtained 
in  the  form  of  a  crystalline  powder  of  a  light  brown  color.  The 
Germans  attempt  to  bleach  the  product  so  obtained,  and  provide 
an  article  at  a  very  high  price  which  is  sometimes  quite  white,  but 
most  of  that  in  the  market  at  a  more  moderate  price  is  of  a  light 
cream  color  with  a  reddish  tinge.  Dr.  Squibb  thinks  that  the  un- 
bleached salicylic  acid  is,  probably,  of  sufficient  purity  for  nearly 
all.  if  not  all.  the  practical  purposes  to  which  the  acid  is  applied, 
while  expensive  chemical  processes  have  to  be  employed  in  order 
to  remove  the  small  amount  of  coloring  matter,  wliifh  more  than 
doubles  the  cost  of  production.  Common  sense  seems  to  show  that 
the  coloring  matter  present  is  not  of  a  kind,  nor  present  in  suffi- 
cient quantity,  to  interfere  with  the  efficacy  of  the  unbleached  pro- 
duct, while  the  high  price  required  for  the  more  or  less  bleached 
product  would  shut  out  from  employment  for  most  purposes,  what- 
ever might  be  its  powers. 

Dr.  Squibb  describes  the  bleached  or  unbleached  acid  as  occur- 
ring in  minute  broken  acicular  crystals,  which  give  it  the  appear- 
ance of  a  granulated  powder,  soft  and  smooth  under  the  pestle  or 
knife,  but  somewhat  rough  or  resinous  when  rubbed  between  the 
fingers.  This  powder  is  odorless  and  nearly  tasteless.  It  has, 
however,  a  sweetish  and  astringent  after-taste,  with  slight  acridity 
in  the  fauces,  but  none  in  the  mouth  ;  and  though  tasteless,  it  h  avos 


512  APPENDIX. 

a  disposition  or  inclination  to  expectorate,  which  continues  for 
some  time. 

Salicylic  acid  is  very  difficultly  soluble  in  cold  water,  but  easily 
dissolved  by  hot  water,  alcohol  and  ether.  An  aqueous  solution 
containing  from  0.2  to"  0.4  per  cent,  of  salicylic  acid  may  be  ob- 
tained by  cofiling  a  hot  solution,  when  the  excess  crystallizes  out. 
The  acid  is  far  more  soluble  in  water  containing  a  small  portion 
of  neutral  salt.  In  Germany  a  solution  is  used  for  surgical  pur- 
poses which  contains  one  gramme  of  the  acid  dissolved  in  fifty 
grammes  of  water  containing  three  grammes  of  sodium  phosphate. 
Salicylic  acid  is  decomposed  into  phenol  and  carbonic  anhydride. 

Its  compounds  with  the  bases  or  salts  seem  difficult  to  make,  but 
salicylate  of  zinc,  a  crystalline  salt  moderately  soluble  in  water, 
and  salicylate  of  quinine,  amorphous,  insoluble  in  water  but  soluble 
in  alcohol,  have  already  been  prepared  in  Germany. 

Dr.  Squibb  very  properly  points  out  that  it  is  in  all  probability 
a  purely  accidental,  although  a  very  curious,  circumstance,  that  a 
substance  of  long  and  well-established  character  as  an  anti-ferment 
should  offiir  a  molecular  constitution  so  well  adapted  to  be  broken 
up  into  a  still  more  powerful  anti-ferment,  for  there  is  no  relation 
whatever,  either  in  composition  or  chemical  or  physical  properties, 
between  carbolic  acid  and  salicylic  acid,  except  in  their  effiicts  by 
similar  or  altogether  different  reactions.  Accordingly,  it  must  not 
be  hastily  assumed  that  in  salicylic  acid  we  have  simply  carbolic  acid 
under  a  new  name,  but  the  compound  must  be  experinjontally 
tested,  compared,  and  then  judged  on  its  merits.  Numerous  ex- 
periments reveal  the  fact  that  salicylic  acid  is  a  powerful  antiseptic ; 
indeed,  it  is  asserted  to  be  far  more  powerful  and  effective  in 
smaller  quantities  than  any  other  antiseptic.  Consequently  its 
innocuous  character,  and  the  absence  of  odor  and  taste  which 
characterize  it,  make  it  immeasurably  superior  to  carbolic  acid, 
which  possesses  qualities  sufficient  to  restrict  its  application  within 
very  narrow  limits.  Other  advantages  which  salicylic  acid  is  said 
to  possess  beyond  all  other  antiseptics  are,  first,  that  it  may  be 
used  in  quantities  sufficient  to  be  completely  effectual  for  surgical 
purposes,  and  yet  devoid  of  any  irritating  action  on  the  living 
tissues,  nor  does  it  produce  inflammation,  nor  any  caustic  or  corro- 


SALICYLIC    ACID.  513 

sive  effect  in  any  quantity.  Although  the  very  small  quantities 
that  are  effectual  are  quite  neutral,  it  is  admitted  that  large  quan- 
tities may  be  irritant  or  painful,  but  not  beyond  what  may  be  de- 
scribed as  a  stimulant.  Secondly,  it  is  said  to  have  power  over 
processes  of  decomposition  which  are  beyond  the  reach  of  all  anti- 
septics or  anti-ferments,  since  it  entirely  suspends  the  chemical 
vitality  which  causes  the  production  of  the  volatile  oils  in  mustard, 
and  bitter  almonds,  the  effect  of  diastase,  etc.  Thirdly,  it  has  no 
poisonous  effect  in  any  reasonable  quantity. 

Brewer's  yeast  does  not  effect  a  solution  of  glucose  to  which 
one-thousandth  part  of  salicylic  acid  has  been  added.  Mustard 
flour,  which,  when  treated  with  a  little  tepid  water,  almost  imme- 
diately develops  a  sharp  odor  of  essence  of  mustard,  remains  quite 
inodorous  if  a  small  quantity  of  salicylic  acid  be  added.  The 
action  of  emulsin,  the  ferment  contained  in  sweet  or  bitter  almonds, 
or  amygdalin,  contained  in  bitter  almonds  only,  whereby  essence  of 
bitter  almonds  is  produced,  is  entirely  prevented  by  salicylic  acid. 
Fresh  milk  mixed  with  0.04  per  cent,  of  salicylic  acid  and  allowed 
to  stand  at  a  temperature  of  80°  F.  in  an  open  vessel  took  thirty- 
six  hours  longer  to  curdle  than  the  same  quantity  similarly  exposed 
in  a  pure  state.  The  neutral  salts  of  salicylic  acid  do  not,  accord- 
ing to  Kolbc,  produce  this  effect,  but  only  the  free  acid.  Beer 
containing  one-thousandth  part  of  salicylic  acid  did  not  become 
sour  when  exposed  to  the  air,  neither  did  it  exhibit  any  trace  of 
that  cryptogamic  vegetation  which  appears  on  the  surface  of  spoiled 
beer.  Eggs  which  have  been  plunged  in  a  solution  of  salicylic 
acid  for  one  hour  remained  unaffected  for  three  months.  Fresh 
meat  on  which  the  acid  had  been  sprinkled  remained  sweet  for 
several  weeks.  It  prevents  or  arrests  the  souring  of  worts,  washes 
and  beers  of  the  brewers,  and  the  putrefivctive  changes  which  are 
so  troublesome  to  the  glue  manufacturers.  Urine  to  which  some 
salicylic  had  been  added  was,  on  the  third  day,  still  clear,  and 
without  ammoniacal  odor.  According  to  the  results  obtained  by 
Professor  Neugebouer,  fermentation  may  be  prevented  by  adding 
100  grammes  of  salicylic  acid  to  1000  litres  of  beer.  The  same 
author  recommends  the  use  of  a  very  weak  solution  of  salicylic  acid 
to  rinse  out  wine  casks,  and  thus  hinder  the  formation  of  mould. 


514  APPENDIX. 

Small  quantities  of  salicylic  acid  would  also,  in  the  estimation  of 
Professor  Neugebouer,  if  added  to  wine,  prevent  that  after  fermen- 
tation which  is  the  principal  cause  of  muddiness  in  wines,  and 
perhaps  check  all  the  wiue  diseases  produced  by  the  growth  of 
fungi.  Professor  Kolbe  finds  that  a  half  a  gramme  of  salicylic 
acid  is  sufficient  to  check  the  further  progress  of  fermentation  pro- 
duced by  the  action  of  5  grammes  of  beer  yeast  on  a  solution  of  120 
grammes  of  sugar  in  1  litre  of  water.  It  has  been  suggested  that 
such  facts  as  these  will  indicate  the  quantities  of  salicylic  acid  to 
be  used  in  the  manufacture  of  fruit  essences,  champagnes,  beer  for 
exportation ;  and  by  way,  perhaps,  of  reassurance  to  those  who 
might  object  to  be  dosed  continuously  with  a  chemical  of  which 
we  know  so  little  as  of  salicylic  acid,  it  is  stated  that  Professor 
Kolbe  could  take  without  disturbing  his  digestion  or  general  health 
from  1  to  1.25  grammes  of  salicylic  acid  per  diem  either  in  water 
or  spirit.  Surely,  however,  an  isolated  experiment  of  this  kind  is 
not  enough  to  establish  the  harmlcssness  of  the  substance  so  as  to 
warrant  its  recommendation  for  general  employment  in  the  prepa- 
ration of  articles  of  food. 

Moreover  Professor  Kolbe  proposes  to  use  this  substance  for  the 
prevention  of  putrefaction  in  water  stored  on  board  of  ships,  the 
object  to  be  attained  either  by  dissolving  the  salicylic  acid  io  the 
water  itself,  in  the  maximum  proportion  of  1  to  20,000,  or  by 
covering  the  bung-holes  of  the  water-casks  with  cotton  impregnated 
with  salicylic  acid.  Would  the  salicylic  acid  be  quite  harmless  if 
used  in  the  former  way  ?  A  suggestion  which  we  should  feel  much 
less  hesitation  in  adopting  personally  is  that  a  capital  dontrifice  may 
be  made  by  perfuming  an  alcoholic  solution  of  salicylic  acid  with 
oil  of  wintergreen.  Used  in  small  quantities,  mixed  with  luke- 
warm water,  it  acts  as  an  effectual  preserver  of  the  teeth ;  or  an  excel- 
lent tooth-powder  may  be  prepared  with  salicylic  acid.  A  "  sprink- 
ling-powder "  for  the  feet  has  also  been  proposed,  which  acts  without 
checking  the  perspiration.  It  should  be  composed  of  salicylic  acid, 
talc,  powdered  soap,  and  starch.  Besides  removing  odor,  it  com- 
municates an  agreeable  softness  to  the  feet. 

The  pho.sphate  of  sodium,  with  a  solution  of  salicylic  acid  was 
employed  by  Professor  Thiersch  to  promote  the  growth  of  skin  over 


SALICYLIC    ACID.  515 

granulated  surfaces.  Or  salicylic  acid  used  alone  or  mixed  with 
starch  was  used  upon  contused  or  incised  wounds,  and  in  operations, 
with  excellent  general  results,  destroying  the  fetid  odor  of  cancer- 
ous surfaces  and  pyaemic  ulcerations. 

We  cannot  over-estimate  the  importance  of  that  branch  of  ex- 
perimental inquiry  which  deals  with  such  questions  as  the  influence 
of  agents  like  carbolic  and  salicylic  acids  on  septic  and  zymotic 
poisoning.  These  investigations  should  be  pushed  to  their  farthest 
limit,  even  if  not  one  in  ten  put  forward  by  chemistry  repay  the 
labor  of  investigation,  for  it  is  certainly  in  this  direction  of  research 
that  medicine  must  look  with  greatest  hope  of  success  to  control 
those  abnormal  vital  processes  which  so  far  may  be  modified  but 
not  stopped.  The  phenols  will  always  retain  their  importance 
among  this  class  of  agents,  surpassing  as  they  do  all  that  have  been 
tried  before  them.  If  salicylic  acid  should  prove  another  step  in 
advance,  the  gain  will  be  great,  more  especially  as  indicating  discov- 
eries which  may  enable  us  to  weild  an  undreamed-of-power  against 
the  most  frightful  and  hitherto  unconquerable  ills  of  humanity. 

In  an  article  wi-itten  under  the  title  of  salicylic  acid,  and  for  the 
Deutsche  Vierteljahrsschri/t  zur  Zahnheilhunde ^  by  Dr.  Osterniann, 
of  Brunswick,  reference  is  made  to  the  experiments  of  Professor 
Kolbe,  and  says  that  in  consequence  of  the  successful  results  of  the 
use  of  salicylic  acid  in  the  hospital,  he  was  led  to  investigate  it  in 
its  application  to  dentistry.  Dr.  Ostermann  first  communicated  the 
results  of  his  observations  at  the  annual  meeting  of  the  Central 
Society  of  Grerman  Dentists. 

The  following  extract,  translated  from  the  article  alluded  to, 
contains  some  of  Dr.  O.'s  observations  concerning  the  application 
of  salicylic  acid  to  dentistry.  W.  T. 

In  cases  where  the  pulps  of  the  teeth  are  changed  through  sup- 
puration and  gangrene  into  a  foul,  disagreeably-smelling,  gas-evol- 
ving mass,  it  is  well  known  that  if  they  are  filled  without  first 
restoring  them  to  a  healthy  condition,  periostitis  will  in  all  proba- 
bility result.  In  such  cases  I  introduce  into  the  nerve  canal 
salicylic  acid  and  then  make  a  temporary  filling,  which  I  allow  to 


516  APPENDIX. 

remain  for  several  days.  In  order  to  make  the  stopping  more 
secure,  I  saturate  a  piece  of  spunk  with  an  ethereal  solution  of 
salicylic  acid,  and  with  it  fill  the  pulp  chamber.  The  results  in  a 
large  number  of  cases  were  good.  The  decaying,  offensive  nerves 
in  the  root  canals  become  fully  deodorized  and  shrink  into  a 
mumified  detritus.  Such  detvital  matter  can  neither  by  evolution 
of  gas  or  putrid  secretions  irritate  through  the  apicial  foramen.  I 
will  here  remark  that  it  may  be  difficult  to  effectively  introduce 
the  dry  salicylic  acid  into  the  root  canals.  If  such  be  the  case,  we  can 
have  recourse  with  advantage  to  a  concentrated  solution  of  the  acid 
in  ether,  which  will  volatilize  in  a  very  few  moments.  This  course 
will  be  especially  indicated  in  the  molar  teeth ;  in  the  incisor  teeth  and 
pulp  cavities  where  cleansing  can  be  conveniently  performed  it  should 
never  be  neglected.  After  washing  the  canals  with  the  above  solu- 
tion, we  saturate  a  piece  of  spunk,  place  in  the  bottom,  and  then 
fill  with  any  material  that  may  be  desirable. 

In  the  treatment  of  suppurating  pulps,  dry  salicylic  acid  may  be 
employed  with  advantage.  In  erosion  and  in  inflamed  conditions 
of  the  mucous  membrane  and  jaws,  I  have  applied  salicylic  acid 
with  success.  In  stomatitis  and  scorbutic  inflammation  of  the 
jaws,  where  the  borders  and  inter-dental  papillse  appear  degener- 
ated, gangrenous,  and  are  coated  with  a  putrid  stringy  secretion,  I 
have  applied  salicylic  acid  mixed  with  equal  parts  of  powdered 
cassia  and  cinnamon  with  a  soft  brush.  The  foul  taste  accom- 
panying such  conditions,  also  the  ill-smelling  breath,  soon  disappear. 
It  may  here  be  added  that  in  every  inflammatory  condition  caused 
by  roots  dead  or  affected  by  periostitis,  salicylic  acid  will  prove  an 
admirable  remedy. 

Aside  from  the  application  of  salicylic  acid  in  special  cases,  I 
have  employed  it  as  an  every-day  means  of  purifying  the  teeth  and 
mouth,  with  the  best  results. 

Fur  a  disinfecting  mouth  wash  :  One  part  of  salicylic  acid  to 
three  hundred  parts  of  water  will  be  sufficient,  or  if  a  stronger  solu- 
tion is  required,  it  may  be  prepared  by  adding  three  parts  of  phos. 
phate  of  soda  and  thirty  parts  of  distilled  water  to  one  of  salicylic 
acid.  It  forms  a  valuable  addition  to  most  tinctures  and  tooth 
powders. 


INDEX. 


Abrasion  chemical,  38. 

Actual  cautery,  310. 

Accidents  in  the  extraction  of  teeth,  431). 

Adaptability,  80. 

Alveolar  abcess,  343. 

treatment  of,  348. 
Amalgam,  93. 
Anaesthetics,  461. 
Appendix,  475. 

Appliances  for  examination,  158, 
Arsenious  acid,  284,  311. 

application  of,  313. 
Atrophy,  31. 

Attachment  of  artificial  crown.  365. 
Automatic  plugger  for  engine,  499. 

Block  filling,  194. 
Breaking  the  teeth,  453. 
Bur  drills,  104,  113. 

Caries  of  the  teeth,  43,  475. 

predisposing  causes,  54, 

exciting  causes,  59. 

consequences  of,  67. 

treatment  of,  70. 

comparative  liability  to,  65. 
Caustics,  alkaline,  287. 
Chloride  of  zinc,  282, 
Chloroform,  464, 

Classification  of  cavities  of  decay,  218, 
Conditions  to  be  observed  in  the  extraction  of  teeth,  434, 
Congelation,  469, 


518  INDEX. 

Cohesive  gold  foil,  231. 

Crystal  or  sponge  gold,  91,  233,  210. 

Creosote  and  carbolic  acid,  280. 

Cylinder  filling,  194. 

Cobalt,  316. 

Dental  periostitis,  335. 

treatment  of,  338. 
Dental  caries,  43,  475. 
Denuding  of  the  teeth,  37. 
Deposits  on  the  teeth,  18. 

points  of,  21. 
Destruction  of  the  pulp,  305. 
Dislocation  of  the  inferior  maxilla,  457. 
Drills,  104. 
Drill  stocks,  103. 

Electro-magnetic  mallet,  495. 

Elevators,  403. 

Ether,  461. 

Examination  of  decays,  157. 

Excavators,  116. 

manufacture  of,  123. 
Exostosis,  34. 
Exposed  pulps,  289. 

treatment  of,  291. 

destruction  of,  305. 
Exclusion  of  moisture,  174. 
Extraction  of  teeth,  376,  410,  432. 
Extraction  of  roots,  419. 
Extracting  instruments,  385. 
Extraction  by  electro-magnetism,  472. 
Extraction  of  the  inferior  incisors,  423. 

Filling  instruments,  125. 
Filling  teeth,  1.56. 

examination  of,  157. 

opening  cavities,  161. 

removal  of  decay,  163. 
Filling  by  classes  and  modifications,  220. 

with  foil,  229. 
Filling  large  cavities  on  the  labial  surfaces  of  superior  incisors.  269. 


INDEX. 


519 


Filling  pulp-cavities  and  canals,  318. 

Finishing  fillings,  213. 

Fitting  the  crown,  363. 

Forming  cavities,  166. 

Forming  blocks,  195. 

Forceps,  391. 

Fracture  of  the  alveolus,  451. 

General  remarks  on  filling,  75. 
Gold,  88. 
Green  tartar,  25. 

its  origin,  26. 

treatment  of,  28. 
Gum  lancet,  406. 

Hyde's  pneumatic  pi  agger,  500. 
Heavy  cutting-instruments,  101. 
Hemorrhage,  440. 

treatment  of,  442. 
Hooks,  404. 


Inferior  bicuspids,  425. 
Inferior  cuspids,  extraction  of,  424. 
Inferior  dens  sapientiae,  extraction  of,  43 1 
Inferior  molars,  extraction  of,  427. 
Instruments  for  filling,  101. 
Introducing  the  filling,  188. 
Introducing  the  blocks,  198. 
Introduction,  17. 
Indications  for  extraction,  383. 
Irregularity  of  the  teeth,  28. 
eflfects  of,  30. 

Laceration  of  the  gums,  453. 
Lead  for  filling,  83. 
Local  anaesthesia,  468. 


Matrices,  502. 

Manufacture  of  excavators,  123. 

Materials  for  filling,  79. 

properties  of,  79. 

non-metallic,  97. 


520  INDEX. 

Metallic  pivots,  370. 

Mode  of  using  the  file,  141. 

Necrosis  of  the  teeth,  41. 

causes  of,  42. 
Nitrate  of  silver,  280, 
Nitrous  oxide,  466. 
Nitric  acid,  480. 

Opening  cavities,  161. 
Oxy-chloride  of  zinc,  96. 

Palmer's  plugging  instrument,  487. 

Pathological  conditions,  372. 

Pellets  for  filling,  201. 

Pivot  teeth,  358. 

Platinum,  86. 

Potential  cautery,  31 1. 

Predisposing  causes  of  caries,  54. 

Preparations  of  gold,  90. 

Preparing  the  teeth  and  roots  for  filling,  325. 

Removal  of  decay,  162. 
Removal  of  the  dens  sapientiae,  42U. 
Removal  of  a  wrong  tooth,  454. 
RuVjber-dam  appliances,  179. 

Salicylic  acid,  510. 

Saliva  pump,  176. 

Screw,  404. 

Separation  of  the  teeth,  145. 

Sensitive  dentine,  272. 

Silver,  86. 

Superior  cuspids,  extraction  of,  412. 

Superior  bicuspids,  extraction  of,  414. 

Superior  molars,  417. 

Syncope,  459. 

Tannin  or  tannic  acid,  279. 
Tartar,  18. 

origin  of,  19. 

points  of  deposit,  21. 


f 


INDEX.  521 

Tartar,  effects  of,  22. 

method  of  removinj!;,  24. 
Terchloride  of  gold,  284. 
The  key,  387. 

The  method  of  lancing  the  gums,  408. 
The  mallet,  205. 
The  file,  138. 

use  of,  141. 
The  palatal  portion  of  the  crown  broken  away,  leaving  the  outer  por- 
tion standing — pulp  not  exposed,  264. 
The  clamps,  179. 
Tin,  84. 

Treatment  of  caries,  70. 
Treatment  of  exposed  pulp,  291. 
Treatment  of  sensitive  dentine,  276. 


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